Patient Satisfaction Survey

General Information

We value each of our patients and would like your opinion on how we can improve our services. Please take a few minutes to complete the survey below. Our goal is to provide the best medical care to all of our patients and families. Your participation will help us continue to improve our services.

Please answer the questions honestly and accurately. The survey is multiple pages, so please remember to answer all of the questions.

Thanks for your time and cooperation!

Question Title

* How did you find out about our practice?

Another doctor recommended

Friend/relative recommended

Insurance

Long time patient

Internet search

Yellow Pages

Other (please specify)

Question Title

* Would you recommend our office to a family member or friend?

Yes

No (If No, why not?)

Question Title

* What is the age range of the patient?

Question Title

* What is your insurance company?

No insurance/Self Pay

Aetna

Anthem/BCBS

Bluegrass Family Health

Cigna

Humana Commercial

Humana Medicare

Medicare

Medicaid

United Healthcare

Other (please specify)

Patient Satisfaction Survey

General Information

Question Title

* How did you find out about our practice?

Question Title

* Would you recommend our office to a family member or friend?

Question Title

* What is the age range of the patient?

Question Title

* What is your insurance company?

Question Title

* What aspects of our practice do you like best?

Question Title

* Please tell us if there is anything we can do to make future visits to our office more pleasant for you and your family?