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Patient Experience Survey

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* 1. Name of physician or nurse practitioner seen at our office:

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* 2. Location

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* 3. Date and timeframe of your appointment (e.g. 1/1/2000, AM):

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* 4. Please rate the overall experience with the telephone receptionist.

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* 5. Please rate your overall experience with the front-desk staff.

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* 6. Please rate your overall experience with the nurse staff.

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* 7. Please rate your overall experience with the physician.

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* 8. The facilities were clean, and the environment appeared to be safe and secure.

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* 9. The practice is accessible, providing an adequate number of routine, urgent, and after-hours appointments.

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* 10. The practice is conveniently located.

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* 11. The practice has convenient hours.

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* 12. The office is easily accessible by phone or electronic messaging.

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* 13. The practice effectively coordinates care, such as notifying you of lab or imaging results and follow-up care (e.g., referrals, ER visits, hospital visits).

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* 14. The practice provides comprehensive healthcare, including routine care, mental health, urgent care, clinical advice, assistance and support.

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* 15. Would you recommend our practice to your friends and family? Why or why not?

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* 16. How can we better serve the needs of you and your child as our patient?

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* 17. Please rate your overall experience at our practice.

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