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No. Questions
1. How long have you been a patient with our office?
2. Approximately how many times have you seen the Dr. in the last year?
6 or more
3. What was the main reason you selected our office?
4. Thinking about your visit to this office, how would you rate it overall? (Circle choice that seems best)
Not Applicable
5. The overall quality of care you received from the Medical Clinic? (1 is very poor, 6 is excellent)
Regarding the quality of service you received during your visit, please rate each of the following (1 is very poor, 6 is excellent)
6. Your ability to get an appointment with the doctor in a non-emergency?
7. The length of lime between making your appointment and the day of your visit?
8. The length of time you spent waiting in Ihe reception area after you arrived for your visit?
9. The length of time you spent waiting in the exam area?
10. The friendliness and courtesy shown to you by the receptionist?
11. The friendliness and courtesy shown to you by the doctor's assistant?
12. The promptness with which you were informed of test results?
13. The convenience and accessibility of our offices?
14. The cleanliness and convenience of our facilities?
15. Your doctor's personal interest in you and your medical problems?
16. The thoroughness of your examination?
17. Your doctor's explanation of treatment options?
18. Your doctor's explanation of test and procedures?
19. Your doctor's explanation of prescribed medicine?
20. The accuracy of the diagnosis you received?
21. Your doctor's explanation for referrals to other physicians and/or Practitioners?
22.. The amount of time spent with the doctor during your visit?
23. Your ability to contact the doctor during office hours?
24.. Your ability to reach any physician after office hours?
25. Would you recommend our office to a friend?
26. Were you contacted by our staff as a reminder prior to your appointment?
27. If yes, please rate your overall impression of this service:
Good Disliked the service
28.. Please provide any additional comments you may have about the services you have received at our office in the space provided or attach an additional sheet. If you would like to be contacted regarding a particular situation, please provide your full name, address and phone number and a brief explanation of the nature of the problem. This information will be maintained confidentially.
Thank you for your time and for sharing your comments with us
 
Name*
Email*
 
 
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