Patient Satisfaction Survey

Please fill out our patient survey

Note: Please skip questions that do not apply.


Name:
Phone:
Email:

Who Did You See Today?:

When you called for an appointment, were you satisfied with the response from the person who answered the telephone?

When you arrived at the office, did you find the receptionist to be friendly and courteous?

When you arrived at the office, did you find the receptionist to be helpful?

How acceptable was the amount of time spent in the reception area and examining room, before seeing the Provider?

When you were called to the examining room, did you find our medical assistant to be friendly and courteous?

When you were called to the examining room, did you find our medical assistant to be competent and professional?

When you were called to the examining room, did you find our medical assistant to be sympathetic and caring?

During your examination, did you find the Provider to be friendly and courteous?

During your examination, did you find the Provider to be competent and professional?

During your examination, did you find the Provider to be sympathetic and caring?

Did the Provider spend an appropriate amount of time with you, answer your questions, and explain medical procedures and treatments to your satisfaction?

How satisfied were you with the Provider's diagnosis and treatment recommendations?

If a procedure was recommended, did the Provider discuss with you, in detail, information regarding the need for the recommended procedure(s) to your satisfaction?

If you had a procedure, were you satisfied with your results?

When asking billing/insurance questions, did you find our billing/insurance staff to be friendly and courteous?

When asking billing/insurance questions, did you find our billing/insurance staff to be helpful?

Rate your overall experience with the practice

Did you like the availability of cosmetic products in our office?:

Would you take advantage of expanded cosmetic services?:

Would you recommend our practice to your friends?:

Additional Comments: