Patient Satisfaction Survey

You are the reason our office is here. We want to provide the best possible service for you in a comfortable and convenient setting and would appreciate your ideas and comments. Please take a moment and rate us on a scale of one to five on the following services. If you prefer, you may download a paper copy of the form to complete and drop in the mail. The postage has been prepaid.

Patient Satisfaction Survey - Download a copy of the survey or complete the form below.

Please rate your level of satisfaction by selecting your answers below:

5 = Very Satisfied • 4 = Satisfied • 3 = Unsatisfied • 2 = Extremely Unsatisfied • 1 = No Opinion

Scheduling
Telephone answered promptly 5 4 3 2 1
Knowledge of person answering call 5 4 3 2 1
Appointment scheduling process 5 4 3 2 1
Appointment time was convenient 5 4 3 2 1
Facility
Parking 5 4 3 2 1
Building appearance 5 4 3 2 1
Registration
Receptionist greeting 5 4 3 2 1
Check-in process 5 4 3 2 1
Check-out process 5 4 3 2 1
Visit
I was seen on time 5 4 3 2 1
I waited a reasonable amount of time 5 4 3 2 1
Approximately how long was your wait? Taken Early No Wait 1-15 mins 16-30 mins 31+ mins
Staff
Physician – I saw: Dr.
Nurse / Clinical Staff 5 4 3 2 1
X-ray Staff 5 4 3 2 1

Overall comments; how can we improve?

How did you select our practice?

Would you recommend us to others? Yes No Don't Know

Thank you for your time and input. All comments will remain confidential.