Satisfaction Survey

1. Did you have trouble locating our office?

1a. If yes, please explain:

2. When I called the office during regular office hours, I received the help or advice I needed.
3. If I had to leave a message, I received a call back that same day.

3a. If no, What was the unreturned call regarding?

4. The front office staff met and greeted me promptly and courteously.
5. The nursing staff greeted me promptly and courteously.
6. The nurses spent an appropriate amount of time with me to understand and communicate my medical needs.
7. How long did you have to wait to see the provider?
8. The provider listened to me and my problems and showed respect and concern for what I had to say.
9. The provider explained things in a way I could understand.
10. The provider spent enough time with me at this visit to discuss the problem I came in for.
11. Which provider(Doctor) did you see?
12. When I checked out, the staff member collected my payment, or explained the insurance billing if needed.
13. If I received a referral to a specialist at my visit, it was handled in a timely manner and to my satisfaction.
14. I was satisfied with how quickly the office was able to arrange an appointment for me.
15. I would recommend your facility to others.
16. The rating I would give the staff and the provider for this visit at your facility:
17. My insurance company is:
18. How would you rate your insurer?

Additional Comments and/or Suggestions:
Full Name: