* How did your learn about our practice?

Physician referralFamilyFriendInsurance companyOther

If other, where did you learn about our practice?

* Was your appointment made within your expected time frame?

Same day1-2 days3-4 daysOther

* Was the person who scheduled your appointment pleasant and courteous?

YesNo

If no, how was the person who scheduled your appointment NOT pleasant and courteous?

* Were you given accurate directions to the office for your appointment?

YesNoI didn't need directions

If you weren't given accurate directions to the office for your appointment, please explain.

* Were you able to have your visit with us at a convenient time?

YesNo

If you weren't able to have your visit with us at a convenient time, please explain.

* Which physician was your appointment scheduled with?

HawthorneRunyanLongoriaDunlapCarrollTreece

* Were your check in and check out procedures handled courteously and efficiently?

YesNo

If your check in and check out procedures weren't handled courteously and efficiently, please explain.

* What was the average wait time after completing the necessary paperwork before you saw the doctor?

5 - 10 minutes15 -20 minutesGreater than 30 minutes

* Was the care and attention of the medical assistant handled courteously and efficiently?

YesNo

If the care and attention of the medical assistant wasn't handled courteously and efficiently, please explain.

* Was the care provided by the physician satisfactory?

YesNo

If the care provided by the physician wasn't satisfactory, please explain.

If you were scheduled for a surgical procedure, was your experience with the surgery scheduler handled courteously and efficiently?

YesNoNA

If no, please explain how your experience with the surgery scheduler wasn't handled courteously and efficiently.

* Were all of your questions answered courteously and professionally by the staff and the physician?

YesNo

If no, please explain how all of your questions weren't answered courteously and professionally by the staff and the physician.

How was the cleanliness/neatness of the waiting room?

ExcellentGoodFairPoor

Please share any comments on the cleanliness of the waiting room.

How would you rate your overall visit experience?

ExcellentGoodFairPoor

Please add any comments you would like to share concerning your overall experience.

Do you have any recommendations of how our services could be improved?