* How did your learn about our practice?

[checkbox* Howdidyourlearnaboutourpractice “physician referral”
“family”
“friend”
“insurance company”
“other”]

If other, where did you learn about our practice?

[textarea Otherhowdidyoulearnaboutourpractice]

* Was your appointment made within your expected time frame?

[radio* appointmentmadeinexpectedtimeframe “Same day”
“1-2 days”
“3-4 days”
“other”]

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

[radio* schedulerpleasant “Yes” “No”]

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

[textarea howschedulewasnotpleasant]

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

[radio* accuratedirections “Yes” “No” “I didn’t need directions”]

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

[textarea notaccuratedirectionsexplain]

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

[radio* convenienttime “Yes” “No”]

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

[textarea notconvenienttimeexplain]

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

[radio* checkinoutprocedures “Yes” “No”]

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

[textarea notcheckinoutproceduresexplain]

* Being a surgical practice, occasionally the doctor is running late due to surgery schedule or seriousness of prior patient’s visit; however we strive to respect your time. What was the average waiting time prior to being seen by the physician following your scheduled appointment time and completion of necessary paperwork?

[radio* averagewaittime “5 – 10 minutes” “15 -20 minutes” “greater than 30 minutes”]

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

[radio* medicalassistantnice “Yes” “No”]

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

[textarea notmedicalassistantniceexplain]

* Was the care provided by the physician satisfactory?

[radio* physiciansatisfactory “Yes” “No”]

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

[textarea notphysiciansatisfactoryexplain]

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

[radio* surgeryschedulersatisfactory “Yes” “No”]

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

[textarea notsurgeryschedulersatisfactoryexplain]

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

[radio* questionsansweredsatisfactory “Yes” “No”]

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

[textarea notquestionsansweredsatisfactoryexplain]

How was the cleanliness/neatness of the waiting room?

[radio* cleanwaitingroom “Excellent” “Good” “Fair” “Poor”]

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

[textarea commentscleanwaitingroom]

How would you rate your overall visit experience?

[radio* overallexperience “Excellent” “Good” “Fair” “Poor”]

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

[textarea commentsoverallexperience]

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

[textarea recommendations]

[submit “Submit Survey Response”]

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