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Patients Satisfaction Survey
1.
What was the nature of your visit today?
Walk in
Appointment
2.
Who was your provider today?
Gregory Walter, NP
Christy Fassbender, NP
Thomas Peterson, NP
Other (please specify)
3.
Overall, how satisfied are you with your visit at IFHS?
Very dissatisfied
1 heart
Somewhat dissatisfied
2 hearts
Neither satisfied nor dissatisfied
3 hearts
Somewhat satisfied
4 hearts
Very satisfied
5 hearts
4.
Please rate your overall experience prior to seeing the clinical staff on a scale of 1 to 5. (1 being very poor and 5 being excellent)
1
2
3
4
5
Wait time in the lobby
1
2
3
4
5
Courtesy of Front Desk Staff
1
2
3
4
5
5.
Please rate your overall experience during your clinical visit on a scale of 1 to 5. (1 being very poor and 5 being excellent)
1
2
3
4
5
Wait time in the exam room
1
2
3
4
5
Provider's service and communication
1
2
3
4
5
6.
Which statements describe your visit? (Select all that apply)
Staff were sensitive to my needs and concerns
Procedures and follow-up plans were explained well
Facility was clean and professional
Other (please specify)
7.
How likely is it that you would recommend IFHS to a friend or colleague? (1 - 10, where 10 is extremely likely)
1 star
2 stars
3 stars
4 stars
5 stars
6 stars
7 stars
8 stars
9 stars
10 stars
8.
OPTIONAL: If you have any additional comments or concerns, please place them here:
If you have any other concerns about your visit today, please complete the attached form or you may request it from our Front Desk receptionist. Thank you.
Grievance Form
Current Progress,
0 of 8 answered
