Patient Satisfaction Survey Question Title * 1. What was the date of your visit? Question Title * 2. Which provider did you see? Dr. Joel Sears Dr. Paul Dunn Dr. Joseph Cvancara Dr. Staci Hestdalen Dr. Andrea Dominey Dr. Chadd Sukut Jeanne Ellern, PA-C Amy Nelson, MPA-C Brenda Wilks, MPA-C Kathy LejaMeyer, ARNP Jacob Wolff, MPA-C Jackie Tschirgi-Master Aesthetician Shanea Pebbles-Master Aesthetician Other Other (please specify) Question Title * 3. Was your appointment scheduled in a timely manner? Yes No Question Title * 4. When you arrived did your appointment occur: Early On time Late Question Title * 5. On a scale from 1 to 5 with 1 being “Poor” and 5 being “Excellent”, how would you rate: 1 2 3 4 5 Ease of check-in Ease of check-in 1 Ease of check-in 2 Ease of check-in 3 Ease of check-in 4 Ease of check-in 5 Front desk staff Front desk staff 1 Front desk staff 2 Front desk staff 3 Front desk staff 4 Front desk staff 5 Medical staff Medical staff 1 Medical staff 2 Medical staff 3 Medical staff 4 Medical staff 5 Provider Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Question Title * 6. Would you recommend our office to friends or family? Yes No Question Title * 7. Comments: Question Title * 8. Name (Optional): Done
