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Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

Please rate each question on how well you think we are doing.
1.Date of visit(Required.)
Date / Time
2.Patient's name (Optional):
3.Patient's age:(Required.)
4.Patient's gender:(Required.)
5.Service site:
6.Ease of getting care:
Poor
Fair
Ok
Good
Great
Ability to get in to be seen.
Hours center is open.
Convenience of center's location.
Prompt return on calls.
7.Waiting:
Poor
Fair
Ok
Good
Great
Time in waiting room.
Time in exam room.
Waiting for tests to be performed.
Waiting for test results.
8.Front desk staff:
Poor
Fair
Ok
Good
Great
Courtesy of person who scheduled your appointment.
Courtesy of staff in the registration process.
9.Providers:
Poor
Fair
Ok
Good
Great
Friendliness / courtesy of the care provider.
Explanation care provider gave you about your problem / condition.
Information care provider gave you about medications / health conditions. (if any)
Instructions the care provider gave you about follow-up. (if any)
Your confidence in this care provider.
Likelihood of you recommending this provider.
10.Providers:
Poor
Fair
Ok
Good
Great
Kim Brunson
Lacey Brown
Stacy Ferrell
Joy Lockhartt
Tiffany Freeman
Lacey Russell
Lori Cummings
Madeline Gebhardt
TaMara Cerniglia
11.Nurses and Medical Assistants:
Poor
Fair
Ok
Good
Great
Friendly and helpful to you.
Answered your questions.
12.Overall Assessment:
Poor
Fair
Ok
Good
Great
Overall cleanliness of our clinic.
Overall rating of care received during your visit.
Likelihood of you recommending our practice to others.
13.In the last 12 months:
Poor
Fair
Ok
Good
Great
How well did we respond to your medical questions in the same day?
How well did we get you an appointment with your provider as soon as you needed it?
How well have we responded to/taken care of your health needs?
14.Please share any suggestions or comments you have about Mercy Medical Health Center:
Current Progress,
0 of 14 answered