Patient Survey

Office Location
Date
Provider Seen
Patient Name (optional)
Patient Email (optional)
Date Visited Office
1 2 3 4 5
Very Dissatisfied Dissatisfied Satisfied Very Satisfied Not Applicable
A. Scheduling Appointments
1. My phone call was answered promptly.
1
 2
 3
 4
 5
2. The person answering the phone call was courteous and helpful.
1
 2
 3
 4
 5
3. It was easy to make an appointment for a physical examination.
1
 2
 3
 4
 5
4. It was easy to make an appointment for a sick visit.
1
 2
 3
 4
 5
B. Office Environment
5. The waiting room was neat and clean.
1
 2
 3
 4
 5
6. The exam room was clean and comfortable.
1
 2
 3
 4
 5
C. Check-In Process
7. The check-in process was prompt and courteous.
1
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 3
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 5
D. Nursing
8. The nursing staff was courteous, efficient, and helpful.
1
 2
 3
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 5
9. The nursing staff responded to my questions.
1
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 5
E. Physician/Nurse Practitioner
10. Your provider spent an adequate amount of time with you/your child.
1
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 5
11. Your provider gave you good quality of care.
1
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 5
12. Your provider gave you appropriate instructions on taking medications.
1
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13. Your provider answered your questions.
1
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 5
F. Check-Out Process
14. The check-out process was prompt and efficient.
1
 2
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 5
G. Billing
15. The billing department was knowledgeable, courteous, and helpful.
1
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 5
H. After Hours Triage
16. The after hours triage service was courteous, helpful, and efficient.
1
 2
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 5
I. General
17. Would you utilize our practice again? Yes     No   
Please tells us why:
18. Would you recommend us to others? Yes     No   
Please tells us why:
19. Is there anything we could have done better or do you have any suggestions.
20. How long did you have to wait to be seen by your provider?

minutes.
21. Please rate your overall experience with our practice.
1
Poor
 2
Fair
 3
Good
 4
Excellent
   
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