**PATIENT SATISFACTION SURVEY**
* Name (optional): Your Insurance Plan:
Doctor's Name (required): Appointment Date (required):
Check appropriate response
* Male Female
* Age: 1 – 25 26 – 35 36 – 45 46 - 55 55 > over
TELEPHONE MANAGEMENT:
Ability to reach the practice by telephone.
Poor Fair Good Very Good Excellent
Your appointment was available within a reasonable amount of time days.
Your appointment was scheduled at a time convenient to you.
RECEPTION MANAGEMENT:
Courtesy and efficiency of the reception staff.
The amount of paperwork you had to fill out.
Instruction on referral requirements.
Appearance and comfort of the reception area.
The amount of time waiting in the reception area. Approximate Time:
CLINICAL & NURSING MANAGEMENT:
Instructions by nurse in the exam room and the willingness to answer your questions.
Courtesy and efficiency of nursing and lab/x-ray staff.
Waiting time in the exam room. minutes.
Appearance and adequacy of the exam room.
Appearance of the clinical staff.
PHYSICIAN TREATMENT:
Physician appearance.
Adequacy and explanation of physician instruction.
Courtesy, caring and respect of physician.
Quality of time spent with physician.
CHECKOUT
Adequacy of follow-up appointment scheduling.
Prescription given, if applicable to you.
Efficiency of payment at the time of service.
Efficiency of the billing process.
Appearance and courtesy of checkout staff.
INSURANCE PLAN INFORMATION: Your Insurance Plan:
Your awareness of your insurance benefits.
Insurance information and assistance provided by the practice staff.
General satisfaction with your insurance carrier.
General satisfaction with the referral process or information from family physician.
OVERALL:
Reason you chose us: Physician reputation Location Phone Book
Insurance Referred by Patient Referred by Dr.
Physician Services Advertisements
Would you recommend our office to others? Yes No
YOUR SUGGESTIONS FOR IMPROVEMENT: