Patient Satisfaction Survey

1. Provider you are seeing today (optional)

Were you completely satisfied with the time spent with your physician or provider today?

Yes

No

Somewhat

Were all of your questions answered today?

Did you have any other comments about your visit?

2. Did our staff discuss with you your financial responsibility for your care or treatment?

Yes

No

3. When do you feel it would be best to discuss your insurance benefits or coverage?

Prior to your initial visit

Following your initial visit

After treatment plan has been determined

Throughout my treatment

Face to face with a staff member

By phone at a time that is convenient for me

Other

4. Was our front desk staff courteous and respectful when you checked in today?

Yes

No

Somewhat

Additional comment/suggestions:

5. When you call our clinic, is the telephone operator friendly and helpful?

Yes

No

N/A

Comments

6. What is an acceptable wait time in our lobby to see your MD (in minutes)?

What is an acceptable waith time in our lobby for scheduling (in minutes)?

7. Is there anything we can provide you with to make your wait more comfortable?

8. Tell us how we can improve our scheduling services?