Audiology Services - UT Dallas Callier Center

1.

 
1. DATE OF SERVICE
MM DD YYYY
When did you have your appointment?
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2. PLACE OF SERVICE AND AUDIOLOGIST
Place of ServiceName of Clinician
Please provide information on your Place of Service and the Name of your Clinician:
*
3. ACCESS TO CARE

PoorFairGoodVery GoodExcellentN/A
Seen for my appointment on time:
Helpfulness of the front office staff:
Insurance information addressed:
Ease of scheduling an appointment:
Able to reach the front office staff during business hours:
Billing concerns or questions were addressed:
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4. AUDIOLOGIST
PoorFairGoodVery GoodExcellentN/A
Evaluation results were explained:
Clear recommendations for further care or treatment were provided:
Written documentation/report received within 15 working days, if requested:
Amount of time spent with you and/or your child:
Understanding and caring shown toward you and/or your family:
All of your questions and concerns were addressed:
Overall quality of care provided by the audiologist:
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5. FACILITY RATING
PoorFairGoodVery GoodExcellentN/A
Cleanliness of treatment/test room:
Cleanliness of restroom:
Comfort of waiting area:
Cleanliness of waiting area:
Availability of parking:
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6. Would you recommend the UTD Callier Center for Communication Disorders to others ?
YesNo
Refer/Recommend ?
7. Was there someone or something that stood out as exceptional (or poor) during your visit ? Please explain:
*
8. PATIENT FOLLOW-UP: Would you like someone to call you to discuss your comments ?
THANK YOU VERY MUCH FOR COMPLETING OUR SURVEY
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