Patient Satisfaction Survey

1. Please rate your experience level regarding the topics listed below:

Experience:
1=Not Satisfied at All       5=Very Satisfied

Your overall experience with your visit
12345N/A

Length of time you waited to make an appointment
12345N/A

Courtesy of the person at the front desk
12345N/A

Friendliness of the person at the front desk
12345N/A

Length of time you waited in the reception area
12345N/A

Courtesy of the person who took you to the exam room
12345N/A

Length of time the healthcare provider spent with you
12345N/A
Check One: PhysicianPhysician Assistant

Explanation of the treatment plan
12345N/A

Length of time available to answer all of your questions
12345N/A

Explanation of the purpose of the prescribed medications, dosages, and any side effects
12345N/A

2. Please rate your level of understanding of the topics below:

1= Do not Understand at All     5=Understand Completely

Your main medical problem
12345N/A

What you need to do about your problem
12345N/A

Why you need to follow instructions
12345N/A

How to contact our office
12345N/A

3. Please tell us how we could improve our service:

4. Please enter your name.

Δ