We would really appreciate your candid (anonymous) feedback on the quality of our care through the following questionnaire,
so that we may continually improve our ability to meet our patient needs!
Please note that these fields are optional and any information provided is strictly for our purposes only. Questions with a (*) are required fields. |
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| Name:
Phone :
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| 1 . Were the waiting room, examination rooms, toilet conditions clean and comfortable? * |
| Very clean Fairly Clean Not very clean Not clean at all |
| 2. Were you greeted in a warm friendly manner by our office staff? * |
| Yes No |
| 3. How long do you have to wait before escorted to the exam room? * |
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15 Minutes
30 Minutes |
| 4. How long do you have to wait before seeing the doctor? * |
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15 Minutes
30 Minutes |
If more than 30 minutes, was there an explanation offered for the delay? This does NOT include waiting, for lab results, treatment, etc. |
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Yes
No |
| 5.Were the office staff courteous and sensitive? * |
| Yes
No |
| 6. Do you have trust and confidence in the physician treating you? * |
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Yes, always
Yes, sometimes
No |
| 7. Were you given enough privacy during treatment? * |
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Yes, always
Yes, sometimes
No |
| 8. Did you find the medical services billed accurately and timely? * |
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Always
Most of the time
Sometimes
Seldom |
| 9. Do you receive electronic balance statements more than once a month? |
| Yes No |
If Yes, How Often?
Weekly
BiWeekly
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| 10. Do you like the web site and its contents? * |
| Yes
Needs improvement |
| Please leave us your comments about our site. |
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| 11. Overall, how would you rate the child care you received? * |
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Excellent
Very good
Good
Fair
Poor |
| Additional Comments |
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Please feel free to make any other comments; we truly do appreciate any information that you can offer us to improve our services. We can only make things better with your input and your opinion is important to us. Once again, “thank-you” for your response.
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