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Patient Satisfaction Survey
Name
*
First
Last
Email
*
Please answer the following question on a 1-5 scale with 5 being the best
*
Indicates required field
Was this your first visit to our office?
*
Yes
No
What was the purpose of your visit?
*
Diagnostic Testing
Follow-up
New Patient/Consultation
Hospital Follow-up
Ease of setting your appointment
*
5
4
3
2
1
Greeting by our receptionist when you arrived
*
5
4
3
2
1
Cleanliness/neatness of the waiting room
*
5
4
3
2
1
Cleanliness/neatness of the procedure suite
*
5
4
3
2
1
Length of time you had to wait before you were called for your appointment
*
5
4
3
2
1
Friendliness of our office staff
*
5
4
3
2
1
Friendliness of the physician
*
5
4
3
2
1
Ability of physician to put you at ease
*
5
4
3
2
1
Quality of the service performed
*
5
4
3
2
1
Degree to which your concerns were addressed by either the technician or the physician
*
5
4
3
2
1
The ease of checking out and paying after the appointment
*
5
4
3
2
1
In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices and procedures.
*
How likely is it that you would recommend our office to your family members, co-workers, and friends?
*
5
4
3
2
1
Submit
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