Patient Experience Survey

Name of physician or nurse practitioner seen at our office:

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

Location

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* 2. Location

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

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

Please rate the overall experience with the telephone receptionist.

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

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

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

Please rate your overall experience with the nurse staff.

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

Please rate your overall experience with the physician.

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

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

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

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

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

The practice is conveniently located.

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* 10. The practice is conveniently located.

The practice has convenient hours.

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* 11. The practice has convenient hours.

The office is easily accessible by phone or electronic messaging.

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

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).

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* 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).

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

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

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

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

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

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

Please rate your overall experience at our practice.

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

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