Patient Experience Survey

* 1. Name of physician or nurse practitioner seen at our office:

* 2. Location

* 3. Date and timeframe of your appointment (e.g. 1/1/2000, AM):

* 4. Please rate the overall experience with the telephone receptionist.

* 5. Please rate your overall experience with the front-desk staff.

* 6. Please rate your overall experience with the nurse staff.

* 7. Please rate your overall experience with the physician.

* 8. The facilities were clean, and the environment appeared to be safe and secure.

* 9. The practice is accessible, providing an adequate number of routine, urgent, and after-hours appointments.

* 10. The practice is conveniently located.

* 11. The practice has convenient hours.

* 12. The office is easily accessible by phone or electronic messaging.

* 13. The practice effectively coordinates care, such as notifying you of lab or imaging results and follow-up care (e.g., referrals, ER visits, hospital visits).

* 14. The practice provides comprehensive healthcare, including routine care, mental health, urgent care, clinical advice, assistance and support.

* 15. Would you recommend our practice to your friends and family? Why or why not?

* 16. How can we better serve the needs of you and your child as our patient?

* 17. Please rate your overall experience at our practice.

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