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Physician Office Survey

PLEASE COMPLETE AFTER YOUR APPOINTMENT

Please help us care for you by providing feedback about your experience with our office and staff.  This feedback helps us continually monitor or change our systems to serve you better.
 

 
Physician Name:  
Date of Visit:    
Your Name:  
E-Mail:    
 
Before Your Visit: How would you rate the following:
 
Ease in getting through to us by phone
 

 

Courtesy of staff taking your call
 

 

Time between making appointment and visit date
 

 

Convenience of office hours
 

 

Ease in seeing the doctor of your choice
 
 
At the time of your visit:

Was our receptionist courteous and helpful?
 

 

Waiting time to see the doctor - How long did you wait?
 

 

Was the nurse courteous and helpful?
 

 

Amount of time doctor spent with you
 

 

Doctor’s explanation of what was done for you
(ie: tests, diagnosis, treatment)
 

 

Doctor’s personal manner (courtesy, respect, sensitivity)
 

 

Doctor’s instructions regarding medications &  follow-up
 

 

Overall quality of care you received
 

 

Were you given enough privacy
 

 

Enough time and comfort to ask questions
 

 

Was our check out person courteous and helpful?
 

 

Likelihood that you would recommend us to a friend or relative

 

 

How easy is our site to navigate?

 
   

How useful is the
information on the site?

 
   

How can we improve the site?

 
   

What would you like
us to add to the site?

 
   

Any other comments or suggestions you might have to help us improve our service would be appreciated!

 
 

         Thank you for taking the time to assist us with these questions.