Please take a few minutes and tell us how we are doing. We appreciate your valuable time and comments. All your responses will be held confidential!
 
Purpose for visit:
 
Who brought you to the physician's office?
Spouse Friend
Parents Public Transportation
Relative Myself
 
Number of people with you:
How much time collectively did you spend waiting in the waiting room and examination room?
5 minutes or less 31-45 miutes
6-15 minutes 46 minutes to 1 hour
16- 30 minutes Over an hour
 
How much time did the physician spend with you?
5 minutes or less
6-15 minutes
Over 15 minutes
 
How would you rate our staff on:
 
Up-to-date medical procedures
Great Fair
Very Good Poor
Good Not Applicable
 
Friendliness
Great Fair
Very Good Poor
Good Not Applicable
 
Patience
Great Fair
Very Good Poor
Good Not Applicable
 
Responsiveness
Great Fair
Very Good Poor
Good Not Applicable
 
Empathy
Great Fair
Very Good Poor
Good Not Applicable
 
Clear Communication
Great Fair
Very Good Poor
Good Not Applicable
 
Clinical knowledge
Great Fair
Very Good Poor
Good Not Applicable
 
Do you feel the physician...
 
Ran or recommended only necessary tests:
Disagree Agree
 
Offered an accurate prognosis:
Disagree Agree
 
Administered caring treatment:
Disagree Agree
 
Would you recommend our medical services to your relatives and friends?
Yes Maybe No
 
What do you consider to be our strengths?
 
What areas of our medical practice could we improve?
 
Name
 
Phone