Survey

Patient's Name(required)

Email(required)

Name of Physician to survey(required)

Daytime Phone(required)

Length of time it took for an appointment(required) Poor

Fair

Good

Very Good

Excellent

Convenience of office location(required) Poor

Fair

Good

Very Good

Excellent

Length of wait at office(required) Poor

Fair

Good

Very Good

Excellent

Amount of time you spent with the physician/health care professional you saw(required) Poor

Fair

Good

Very Good

Excellent

Explanation of what was done for you by physician(required) Poor

Fair

Good

Very Good

Excellent

Technical skills of physician/health care professional (thoroughness, carefulness, competence)(required) Poor

Fair

Good

Very Good

Excellent

Personal manner (courtesy, respect, sensitivity, friendliness) The physician/health care professional you saw(required) Poor

Fair

Good

Very Good

Excellent

Nursing staff(required) Poor

Fair

Good

Very Good

Exellent

Reception staff(required) Poor

Fair

Good

Very Good

Excellent

Overall visit(required) Poor

Fair

Good

Very Good

Excellent

In general, would you say your health is(required) Poor

Fair

Good

Very Good

Excellent

Would you recommend the physician/health care professional you saw to your family or friends?(required) Definitely Yes

Probably Yes

Probably Not

Definitely Not

Are you a male or female?(required) Male

Female

How old were you on your last birthday?(required)

Personal Comments (Optional)

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