Dear Patient: Please choose the provider you saw from the list below and tell us your opinion about the service you received. Your responses will be kept strictly confidential. Thanks for your help.
Name:
Email:
Provider Seen:
PLEASE RATE THE FOLLOWING:
A. YOUR APPOINTMENT:
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. Ease of making appointments by phone
2. Appointment available within a reasonable amount of time
3. Getting care for illness/condition as soon as you wanted it
4. Getting after-hours care when you needed it
5. The efficiency of the check-in process
6. Waiting time in the reception area
7. Waiting time in the exam room
8. Keeping you informed if your appointment time was delayed
9. Ease of getting a referral when you needed one
B. OUR STAFF:
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. The courtesy of the person who took your call
2. The friendliness and courtesy of the receptionist
3. The caring/concern of our nurses/medical assistants
4. The helpfulness of the people in our business office
C. OUR COMMUNICATION WITH YOU:
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. Your phone calls answered promptly
2. Getting advice or help when needed during office hours
3. Explanation of your procedure (if applicable)
4. Your test results reported in a reasonable amount of time
5. Effectiveness of our health information materials/pamphlets
6. Our ability to return your calls in a timely manner
7. Your ability to contact us after hours
8. Your ability to obtain prescription refills by phone
D. YOUR VISIT WITH THE PROVIDER: (Doctor, Midwife, Nurse Practitioner)
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. Willingness to listen carefully to you
2. Taking time to answer your questions
3. Amount of time spent with you
4. Explaining things in a way you could understand
5. Instructions regarding medication/follow-up care
6. The thoroughness of the examination
7. Advice given to you on ways to stay healthy
E. OUR FACILITY:
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. Hours of operation convenient for you
2. Overall comfort
3. Adequate parking
4. Signage and directions easy to follow
F. YOUR OVERALL SATISFACTION WITH:
Excellent
Very Good
Good
Fair
Poor
Does Not Apply
1. Our practice
2. The quality of your medical care
3. Overall rating of care from your personal doctor or nurse
WOULD YOU RECOMMEND THE PROVIDER TO OTHERS?
IF NO, PLEASE TELL US WHY:
HOW DID YOU HEAR ABOUT OUR OFFICE?
IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:
