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Dental Patient Satisfaction Survey
*
1.
Which provider did you see today?
(Required.)
Dr Juneja
Dr Emerick
Christine Stanford
Kathy Pifer
Dr Branton
Rechawn Fair
Dr Merhi
Dr. Syeda
Dr. Pierce
Other (please specify)
*
2.
Where were you seen today?
(Required.)
Adrian
Carleton
Temperance
3.
I am able to get through to the office on the phone during office hours
Always
Sometimes
Rarely
Never
4.
In the last 12 months, when you phoned your dentist's office after regular office hours, how often did you get an answer to your question as soon as you needed?
Never
Sometimes
Usually
Always
N/A
5.
How convenient was the appointment time you were able to get?
Extremely convenient
Very convenient
Somewhat convenient
Not so convenient
Not at all convenient
If not, what would make it more convenient?
6.
How easy is it to schedule urgent appointments with your dentist?
Extremely easy
Very easy
Moderately easy
Slightly easy
Not at all easy
N/A
7.
How courteous and helpful was the receptionist when you arrived at our office?
Extremely
Very
Somewhat
Not very
Not at all
8.
How friendly was the clinical staff during your visit?
Extremely friendly
Very friendly
Somewhat friendly
Not so friendly
Not at all friendly
9.
Did you observe the dental staff wash their hands or use hand sanitizer?
Yes
No
10.
Overall, how often do you wait more than 15 minutes to see your dentist or hygienist? (Wait time includes time spent in the waiting room and exam room.)
Always
Most of the time
About half of the time
Once in a while
Never
11.
How satisfied or dissatisfied were you with the amount of time your dentist or hygienist spent with you addressing your needs?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
12.
Were your needs met at this visit?
Extremely well
Very well
Somewhat well
Not so well
Not at all
13.
Did anyone talk to you about the medication you take?
Yes
No
14.
Were you asked if you had visits with other health care providers since your last visit?
Yes
No
15.
Did anyone help you make an appointment with a specialty provider if necessary?
Yes
No
NA
16.
Have we ever given you information about FMC being your medical home?
Yes
No
17.
Have we ever helped you find other community resources you might need that FMC does not provide?
Yes
No
NA
18.
Do you feel that what you pay for your care is reasonable?
Extremely reasonable
Very reasonable
Somewhat reasonable
Not very reasonable
Not at all reasonable
19.
May we contact you for further input regarding your thoughts on FMC?
Yes
No
If yes, please supply preferred contact information
*
20.
Would you recommend FMC to your friends and family?
(Required.)
Definitely no
Probably no
Probably yes
Definitely yes
21.
How did you hear about Family Medical Center?
Family/Friends
Direct mailing/Letter from FMC
Newspaper/Magazine Ad
Internet Search
Health Insurance
Health Department/WIC/Monroe County Community Mental Health
Hospital
School/Work
Community Event
Other (please specify)
22.
Do you have any comments or suggestions?
*
23.
Is this your first visit to Family Medical Center?
(Required.)
Yes
No