Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

0 - No Answer / Not Applicable, 1 - Poor, 2 - Fair, 3 - OK, 4 - Good, 5 - Great


About You
1. Your age:*
2. Your sex:* Male Female
3. Your Race/Ethnicity?

Ease of getting care
4. Ability to get in to be seen 0 1 2 3 4 5
5. Hours Center is open 0 1 2 3 4 5
6. Convenience of Center's location 0 1 2 3 4 5
7. Prompt return on calls 0 1 2 3 4 5

Waiting
8. Time in waiting room 0 1 2 3 4 5
9. Time in exam room 0 1 2 3 4 5
10. Waiting for test to be performed 0 1 2 3 4 5
11. Waiting for test results 0 1 2 3 4 5

Staff: Provider (Physician,Physician Assistant, Physical Therapist, Medical Assistant)
12. Listens to you 0 1 2 3 4 5
13. Takes enough time with you 0 1 2 3 4 5
14. Explains what you want to know 0 1 2 3 4 5
15. Gives you good advice and treatment 0 1 2 3 4 5

Staff: Physician Assistants and Medical Assistants
16. Friendly and helpful to you 0 1 2 3 4 5
17. Answers your questions 0 1 2 3 4 5

Staff: All Others
18. Friendly and helpful to you 0 1 2 3 4 5
19. Answers your questions 0 1 2 3 4 5

Payment
20. What you pay 0 1 2 3 4 5
21. Explanation of charges 0 1 2 3 4 5
22. Collection of payment/money 0 1 2 3 4 5

Facility
23. Neat and clean 0 1 2 3 4 5
24. Ease of finding where to go 0 1 2 3 4 5
25. Comfort and safety while waiting 0 1 2 3 4 5
26. Privacy 0 1 2 3 4 5

Confidentiality
27. Keeping my personal information private 0 1 2 3 4 5

Overall
28. The likelihood of referring your friends and relatives to us: 0 1 2 3 4 5
29. Do you consider this center your regular source of care? Yes No
30. What do you like best about our center?
31. What do you like least about our center?
32. Suggestions for improvement?

 

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