Tell Us How We Can Serve You Better

Using the legend below, please circle the number following each question that corresponds with your answer. For example, if your answer to the first question is "excellent", you will circle the number "1". If you do not have sufficient knowledge to answer a question, please circle "6", don’t know.

LEGEND:
1 = Excellent
2 = Above Average
3 = Average
4 = Below Average
5 = Poor
6 = Don’t Know

All questions, except the name field, require an answer.

Your name: (optional)
Email: (required)
  1. How did you decide to come to this practice?
  2. When you telephone our office, how would you rate the service you received over the phone?
    123456
  3. How would you rate the ease and timeliness of obtaining an appointment?
    123456
  4. During your last visit to our office, how would you rate your treatment by our staff?
    123456
  5. How would you rate our interest in you as a person when you visit the office?
    123456
  6. How would you rate our reception area?
    123456
  7. How would you rate the overall quality of care you receive?
    123456
  8. How would you rate the doctor on patience, warmth and interest in your care?
    123456
  9. How would you rate the surgeon's explanation of the illness, treatments available or surgical procedures?
    123456
  10. How would you rate the scheduling process in our office for setting up your surgery?
    123456
  11. When you arrive at our office, how long do you normally have to wait after your scheduled appointment time?
  12. If you wait longer than 15 minutes, are you given an explanation for the delay?
    YesNoUndecided
  13. Knowing what you know now, would you still choose us for your surgery and, would you recommend us to someone else?
    YesNoUndecided
  14. How would you rate your overall experience with our program?
    123456
  15. Is there anything that would have made your overall experience better?
  16. Do you want to identify anyone on the Hospital and / or Physician staff that you would like to make a comment about?
  17. Please enter the date of your appointment:
  18. Would you like to leave us your name? (optional)