Patient Satisfaction Survey

Q.1

Which doctor did you visit? *

Q.2

Patient Name (Optional)

Title

First Name

Last Name

Q.3

Please rate our services from 1 - 5, 1 being poor and 5 being excellent *

	1	2	3	4	5	Not Applicable
Friendliness of our phone staff
Ease of booking an appointment
Wait time for your appointment (s)
Friendliness of our front office staff
Friendliness of our clinical staff
Friendliness of our doctor
Quality of care received
Quality of care test results
Overall office visit

Friendliness of our phone staff

1 2 3 4 5 Not Applicable

Ease of booking an appointment

1 2 3 4 5 Not Applicable

Wait time for your appointment (s)

1 2 3 4 5 Not Applicable

Friendliness of our front office staff

1 2 3 4 5 Not Applicable

Friendliness of our clinical staff

1 2 3 4 5 Not Applicable

Friendliness of our doctor

1 2 3 4 5 Not Applicable

Quality of care received

1 2 3 4 5 Not Applicable

Quality of care test results

1 2 3 4 5 Not Applicable

Overall office visit

1 2 3 4 5 Not Applicable

Q.4

Phone (Optional)

Phone Number

Q.5

Cell (Optional)

Phone Number

Q.6

E-mail Address (Optional)

Email

Q.7

What is your preferred method of communication? *

Q.8

Additional comments or suggestions