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Patient Satisfaction Survey

Patient Satisfaction Survey

We would appreciate your taking a few minutes to help us provide you with excellent service. Please complete the questions below and submit your survey. Thank you for your help.

* = Required Field

Appointment Date*

Physician*

New patient?	Yes No

How did you hear about our practice?
Your Appointment
Did you request your appointment on-line?	Yes No

Ease of scheduling by phone	Excellent Good Fair Poor N/A

Appointment availability and convenience	Excellent Good Fair Poor N/A

Exam Room waiting time	Excellent Good Fair Poor N/A

Our Staff
Courtesy of person who took your call	Excellent Good Fair Poor N/A

Friendliness & courtesy of check-in	Excellent Good Fair Poor N/A

Caring/concern of our nusring staff	Excellent Good Fair Poor N/A

Helpfulness of our Insurance Department	Excellent Good Fair Poor N/A

Would you like to comment on a specific staff member?

Please rate your entire experience with:
Your visit with the doctor	Excellent Good Fair Poor N/A

Our practice	Excellent Good Fair Poor N/A

Would you recommend our practice to others? Please comment why below	Yes No

Additional Comments


Would like a member of our staff to contact you to discuss your feedback?
	Yes No

If you answered "yes," please provide your contact information:
Name:

Phone Number: