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Patients Satisfaction Survey
1.
Check your respond below,
Walk in
Appointment
2.
Who was your provider today?
Gregory Walter, NP
Christy Fassbender, NP
Thomas Peterson, NP
Other (please specify)
3.
How would you rate your provider's service today?
Very dissatisfied
1 star
Somewhat dissatisfied
2 stars
Neither satisfied nor dissatisfied
3 stars
Somewhat satisfied
4 stars
Very satisfied
5 stars
N/A
Other (please specify)
4.
Which of the following statements would you use to describe your visit at IFHS today? Select all that apply.
Reliable
Front Desk - courteous and respectful
Provider / clinician - explained procedures well
Provider / clinician - provide follow-up plan
Provider / clinician - sensitive to my needs and concerns
Staff were not sensitive to my needs
Provider / clinician did not provide attentive care and were not helpful
Facility is not clean
Poor quality care
Unreliable
Other (please specify)
5.
How long was your wait time at the lobby?
Within 5 minutes after check-in
Within 15 minutes after check-in
Within 30 minutes after check-in
More than 30 minutes after check-in
6.
How long was your wait time in the exam room before you were seen by the provider?
Within 15 minutes of entering the room
Within 30 minutes waiting in the room
1 hour or more
7.
How well do we meet your needs?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
8.
How long have you been a patient at IFHS?
This is my first visit
Less than six months
Six months to a year
1 - 2 years
3 or more years
9.
How likely are you to return to IFHS for treatment?
Extremely likely
Very likely
Somewhat likely
Not so likely
Not at all likely
10.
Overall, how satisfied or dissatisfied are you with your visit at IFHS?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
11.
On a scale of 0 to 10,
How likely is it that you would recommend IFHS to a friend or colleague?
0 for Not at all likely, 10 for Extremely likely
Not at all likely
Extremely likely
0
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12.
Do you have any questions, comments or concerns?
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
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