Patient Survey

Dear Patient,

Your opinions are very valuable in helping us serve your and your family. Please take a few minutes to complete this brief, confidential survey. If your answers are not submitted electronically, please deposit in the secured survey box once completed.

Thank you

Which provider did you see?

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1. Which provider did you see?

In the past 12 months, how many times did you have to see someone else when you wanted to see your own personal provider?

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2. In the past 12 months, how many times did you have to see someone else when you wanted to see your own personal provider?

What was the date of your appointment?

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3. What was the date of your appointment?

Date
I have been a patient at this practice:

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4. I have been a patient at this practice:

I found out about this practice through:

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5. I found out about this practice through:

I chose this practice because

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6. I chose this practice because

How do you rate the quality of pre-appointment services?

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7. How do you rate the quality of pre-appointment services?

  Excellent Very Good Good Fair Poor
a. Ease of getting through to our office by telephone
b. Length of wait time in obtaining an appointment
c. The ease of obtaining the appointment time of your choice
How do you rate the quality of appointment services?

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8. How do you rate the quality of appointment services?

  Excellent Very Good Good Fair Poor
a. Length of wait time in the reception area
b. Length of wait time in the exam room
c. Explanation or notification by staff of possible wait time
d. Friendliness, sensitivity, and courtesy received from the reception staff
e. Friendliness, sensitivity, and courtesy received from the nursing staff
f. Thoroughness of examination and amount of time spent with your doctor/provider
g. Explanation of diagnosis and medical instructions
h. Friendliness, sensitivity, and courtesy received from your doctor/provider/aesthetician
i. Length of wait time at checkout
j. Overall quality of healthcare provided at this office
Please rate the quality of telephone services as it pertains to:

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9. Please rate the quality of telephone services as it pertains to:

  Excellent Very Good Good Fair Poor N/A
a. Prescription refills
b. Medical questions
c. Test results
d. Appointment scheduling
e. Billing questions
f. After-hours answering service
Quality of other services

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10. Quality of other services

  Excellent Very Good Good Fair Poor
a. Cleanlines and comfort of this office
b. Convenience of our location
c. Convenience and adequacy of parking
In the past 12 months, how many times have you gone to a walk-in clinic (i.e. Minute Clinic, Immediate Care Center, etc.) due to their extended hours on weekdays and weekends?

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11. In the past 12 months, how many times have you gone to a walk-in clinic (i.e. Minute Clinic, Immediate Care Center, etc.) due to their extended hours on weekdays and weekends?

If we were to offer extended hours, which would you prefer?

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12. If we were to offer extended hours, which would you prefer?

Would you refer your family and friends to our office?

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13. Would you refer your family and friends to our office?

What improvements can we make to better serve you?

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14. What improvements can we make to better serve you?

Thank you for your time!

T