Patient Satisfaction Survey

How would you rate your overall service experience with our practice?

Excellent Good Fair Poor

Please rate the following (scale of 1 to 5, with 5 being the best):

Phone manners of our staff ........................ 1 2 3 4 5
Convenience of your appointment time ...... 1 2 3 4 5
Greeting upon arrival ............................... .. 1 2 3 4 5
Helpfulness of our staff ............................... 1 2 3 4 5
Sensitivity and attentiveness of doctor and staff
1 2 3 4 5
Explainations provided/questions answered?
1 2 3 4 5
Do you feel positive enough about our practice to refer family and friends?
Yes No

Please comment on anything regarding our service that we might change to make your future experiences with us even more positive.

Did any staff members go out of their way to make your visit more pleasant of comfortable? If so, will you provide us with their names so that we may show our recognition?

Name (optional)

May we share your comments with others?
Yes No

Verification Code (case sensitive):

Thank you for your time!