Your opinion is very important! So that we can provide our patients with the best care possible, we would like your thoughts. Please fill out this questionnaire regarding your care. Your input will be taken into careful consideration. As well, by completing this survey with your name, address and phone number, you will be eligible for our periodic drawing for a $25.00 mall gift certificate.

* 1. Which physician cared for you on your latest visit?

* 2. What factors influenced you to choose our office?

* 3. If you were referred by another physician, please give name and specialty

* 4. Did you have to wait to see the doctor?

* 5. Please rate the following:

  Poor Excellent N/A
Physician
Reception room staff
Nursing staff
Office Appearance
Satisfaction with explanation of your condition and treatment plan
Satisfaction with the handling of your insurance and billing
Overall satisfaction

* 6. What was the most positive aspect of your visit to our office?

* 7. Are there any areas you think we can improve upon to serve our patients better?

* 8. If available, would you like to update your information on the interent?

* 9. Optional: (Required to be eligible for gift certificate drawing) Please provide your name, address and phone number

Report a problem

T