Customer Satisfaction Survey

Dear Valued Patient,

Please complete this survey as truthfully as possible. Your input is important to us and would like to know how we can better serve you.

Name

Date of most recent visit *

 

How often...

Are you greeted warmly when you arrive?	SometimesAlwaysNeverN/A
Do you feel comfortable asking the staff questions?	SometimesAlwaysNeverN/A
Do you find the information provided to you by the staff to be correct and helpful?	SometimesAlwaysNeverN/A
Does the staff handle your requests/ concerns in a timely and appropriate manner?	SometimesAlwaysNeverN/A
Do we go out of our way to make sure you know when your next appointment is?	SometimesAlwaysNeverN/A

 

How would you rate the time it takes to schedule an appointment?	ExcellentGoodNeeds ImprovementPoor
How would you rate the convenience of the office hours?	ExcellentGoodNeeds ImprovementPoor
How much time passes between your appointment time and the time you receive service?	ExcellentGoodNeeds ImprovementPoor
How would you rate the time it takes to get a prescription refilled?	ExcellentGoodNeeds ImprovementPoor
How would you rate the time it takes to get a call back from our office?	ExcellentGoodNeeds ImprovementPoor
How satisfied are you with the staff's efforts to make sure that all of your needs are met?	ExcellentGoodNeeds ImprovementPoor
How satisfied are you with the quality of the service you receive?	ExcellentGoodNeeds ImprovementPoor
How would you rate the friendliness of the staff?	ExcellentGoodNeeds ImprovementPoor
How would you rate the time it takes to get a live person on the phone?	ExcellentGoodNeeds ImprovementPoor
How would you rate the parking?	ExcellentGoodNeeds ImprovementPoor
How highly would you recommend this clinic to others?	ExcellentGoodNeeds ImprovementPoor

Do you have any suggestions on how we may improve?

 

Would it be ok to post your comments on our website? *

YesNo