Customer Satisfaction Survey

Patient Name (*Optional):

Did you schedule in advanced or walk in?

The person who managed my appointment was: Very Courteous, Good, Fair, Needs Improvement, Rushed, Rude

The staff at the reception desk: Very Courteous, Good, Fair, Needs Improvement, Rushed, or Rude?

Estimated time in waiting reception/waiting area?

Exam room estimated wait?

The competence and courteousness of the Patient Care Coordinator was: Outstanding, Good, Adequate, Needs Improvement, Poor, or NA

How well did the billing staff explain your insurance coverage: Outstanding, Good, Adequate, Needs Improvement, Poor, or NA

Were you told the anticipated amount owed before check out?

Do you feel that the clinician spent an adequate amount of time explaining the function of your prescribed item(s)?

Characterize the demeanor of the clinician: Attentive, Concerned, Friendly, Distracted, Rushed, or Inconsiderate

Were you given adequate instructions on wear, care, and function of the prescribed item(s)?

Were you given the clinician’s business card?

Was the lobby clean?

Was the exam room clean and tidy?

On a scale of 1-3 (with 3 being complete satisfaction), how would you rate your experience with us?

Would you recommend this facility to your family and friends?

Please provide your number if you would like to be given a call (*Optional)

Please provide your email If you would like to be contacted: (*Optional)

Please share any additional comments and list any areas where you feel we excelled or areas in which our services could be improved upon: