Background Information

Date Of Visit:

How many minutes did you wait after your scheduled appointment before you we called into an exam room?

How many minutes did you wait in the exam room before you were seen by the physician?

Appointment Scheduling

Ease of making your appointment: Very Poor  Poor  Fair  Good  Very Good

Courtesy of person making your appointment: Very Poor  Poor  Fair  Good  Very Good

Our helpfulness on the telephone: Very Poor  Poor  Fair  Good  Very Good

Comments: (please describe good or bad experience)

Your Visit

Ease of registration process: Very Poor  Poor  Fair  Good  Very Good

Comfort and pleasantness of waiting area: Very Poor  Poor  Fair  Good  Very Good

Length of wait before going into exam room: Very Poor  Poor  Fair  Good  Very Good

Comfort and pleasantness of exam room: Very Poor  Poor  Fair  Good  Very Good

Friendliness / courtesy of nurse: Very Poor  Poor  Fair  Good  Very Good

Concern nurse showed for your problem: Very Poor  Poor  Fair  Good  Very Good

Waiting time in exam room before seeing physician: Very Poor  Poor  Fair  Good  Very Good

Comments: (please describe good or bad experience)

Your Physician

Friendliness / courtesy of physician: Very Poor  Poor  Fair  Good  Very Good

Explanations the physician gave you: Very Poor  Poor  Fair  Good  Very Good

Concern the physician showed for your problem: Very Poor  Poor  Fair  Good  Very Good

Information the physician gave about medications (if any): Very Poor  Poor  Fair  Good  Very Good

Information the physician gave about follow up (if any): Very Poor  Poor  Fair  Good  Very Good

Degree the physician talked with you in words you can understand: Very Poor  Poor  Fair  Good  Very Good

Amount of time the physician spent with you: Very Poor   Poor  Fair  Good  Very Good

Your confidence in this provider: Very Poor  Poor  Fair  Good  Very Good

Likelihood of you recommending this physician to others: Very Poor  Poor  Fair  Good  Very Good

Comments: (please describe good or bad experience)

Personal / Overall

Convenience of our office hours: Very Poor  Poor  Fair  Good  Very Good

Our sensitivity to your needs: Very Poor  Poor  Fair  Good  Very Good

Our concern for your privacy: Very Poor  Poor  Fair  Good  Very Good

Cheerfulness of our practice: Very Poor  Poor  Fair  Good  Very Good

Cleanliness of our practice: Very Poor  Poor  Fair  Good  Very Good

How well our staff worked together to take care of you and your family: Very Poor  Poor  Fair  Good  Very Good

Likelihood of you recommending our practice to others: Very Poor  Poor  Fair  Good   Very Good

Comments: (please describe good or bad experience)

Any other services you would like to see our practice offer or other suggestions:

Would you like to see our physicians go to other hospitals: Yes   No

If yes, which

Comments on this site if any:

Patient's name (optional)

Patient's number (optional)

Please be sure to answer ALL questions before clicking on the SUBMIT button below. Failure to do so will generate and error and you must return to this page to complete the form. Use the RESET button to start over and blank all boxes. To eliminate "spam bots" and prove you are a human submitting this form, please identify the below picture: