IPD Provider Post-Visit Patient Satisfaction Template

Question Title

* 1. Which Provider did you see today?

Question Title

* 2. How likely is it that you would recommend your provider to a friend or family member?

NOT AT ALL LIKELY

EXTREMELY LIKELY

0

1

2

3

4

5

6

7

8

9

10

Not at all likely - 0

1

2

3

4

5

6

7

8

9

Extremely likely - 10

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* 3. Overall, how would you rate the care you received from your Provider?

Excellent

Very good

Good

Fair

Poor

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* 4. Overall, how would you rate the service you received from the staff at our office?

Excellent

Very good

Good

Fair

Poor

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* 5. How comfortable was the lobby and waiting area?

Extremely comfortable

Very comfortable

Somewhat comfortable

Not so comfortable

Not at all comfortable

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* 6. Is there anything we could have done to improve your last visit?