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Patient Satisfaction Survey

Dear Patient,

Thank you for visiting us. By filling out this quick 5-10 minute survey, you will help us to provide better care in future.

1 Gender?
Required answer

2 Age?
Required answer

3 Race / Ethnicity?
Required answer

4 How would you rate the speed of care given?
Required answer

Excellent
Good
Fair
Poor
Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for test results

5 How would you rate the ease of getting care?
Required answer

Excellent
Good
Fair
Poor
Ability to get in to be seen make an appointment
Hours center (hospital) is open
Convenience of center's (hospital's) location
Prompt return of calls

6 Which physician were you seen by?
Required answer

7 How would you rate your Physician, Nurse, Other medical staff
Required answer

Excellent
Good
Fair
Poor
Listens to you and takes enough time with you
Explains what you want to know
Gives you good advice and treatment
Friendly and helpful to you
Answers your questions

8 How would you rate all other staff (support, tech, etc.) attitude?
Required answer

Excellent
Good
Fair
Poor
Friendly and helpful to you
Answers your questions

9 How would you rate your feeling about the facilities?
Required answer

Excellent
Good
Fair
Poor
Neat and clean
Ease of finding where to go
Comfort and Safety
Privacy

10 How would you rate the cost of our services?
Required answer

11 How would you rate our billing?
Required answer

Excellent
Good
Fair
Poor
Explanation of charges
Collection of payments

12 Would you recommend us to your friends or relatives?
Required answer

13 What do you like / dislike about our center (hospital)?
Required answer

1500 characters remaining

14 What can we do better?
Required answer

1500 characters remaining