Patient Survey

PLEASE RATE THE FOLLOWING ABOUT YOUR APPOINTMENT

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
Ease of making appointments by telephone	ExcellentEase of making appointments by telephone Excellent	Very GoodEase of making appointments by telephone Very Good	GoodEase of making appointments by telephone Good	FairEase of making appointments by telephone Fair	PoorEase of making appointments by telephone Poor	Not ApplicableEase of making appointments by telephone Not Applicable
Appointment available within reasonable amount of time	ExcellentAppointment available within reasonable amount of time Excellent	Very GoodAppointment available within reasonable amount of time Very Good	GoodAppointment available within reasonable amount of time Good	FairAppointment available within reasonable amount of time Fair	PoorAppointment available within reasonable amount of time Poor	Not ApplicableAppointment available within reasonable amount of time Not Applicable
The efficiency of the check in process	ExcellentThe efficiency of the check in process Excellent	Very GoodThe efficiency of the check in process Very Good	GoodThe efficiency of the check in process Good	FairThe efficiency of the check in process Fair	PoorThe efficiency of the check in process Poor	Not ApplicableThe efficiency of the check in process Not Applicable
Waiting time in the lobby	ExcellentWaiting time in the lobby Excellent	Very GoodWaiting time in the lobby Very Good	GoodWaiting time in the lobby Good	FairWaiting time in the lobby Fair	PoorWaiting time in the lobby Poor	Not ApplicableWaiting time in the lobby Not Applicable
Waiting time in the exam room	ExcellentWaiting time in the exam room Excellent	Very GoodWaiting time in the exam room Very Good	GoodWaiting time in the exam room Good	FairWaiting time in the exam room Fair	PoorWaiting time in the exam room Poor	Not ApplicableWaiting time in the exam room Not Applicable
Keeping you informed if your appointment time was delayed	ExcellentKeeping you informed if your appointment time was delayed Excellent	Very GoodKeeping you informed if your appointment time was delayed Very Good	GoodKeeping you informed if your appointment time was delayed Good	FairKeeping you informed if your appointment time was delayed Fair	PoorKeeping you informed if your appointment time was delayed Poor	Not ApplicableKeeping you informed if your appointment time was delayed Not Applicable

PLEASE RATE THE FOLLOWING ABOUT OUR STAFF

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
The courtesy of the person who took your call	ExcellentThe courtesy of the person who took your call Excellent	Very GoodThe courtesy of the person who took your call Very Good	GoodThe courtesy of the person who took your call Good	FairThe courtesy of the person who took your call Fair	PoorThe courtesy of the person who took your call Poor	Not ApplicableThe courtesy of the person who took your call Not Applicable
The friendliness and courtesy of the receptionist	ExcellentThe friendliness and courtesy of the receptionist Excellent	Very GoodThe friendliness and courtesy of the receptionist Very Good	GoodThe friendliness and courtesy of the receptionist Good	FairThe friendliness and courtesy of the receptionist Fair	PoorThe friendliness and courtesy of the receptionist Poor	Not ApplicableThe friendliness and courtesy of the receptionist Not Applicable
The helpfulness of the people who assisted you with billing and/or insurance	ExcellentThe helpfulness of the people who assisted you with billing and/or insurance Excellent	Very GoodThe helpfulness of the people who assisted you with billing and/or insurance Very Good	GoodThe helpfulness of the people who assisted you with billing and/or insurance Good	FairThe helpfulness of the people who assisted you with billing and/or insurance Fair	PoorThe helpfulness of the people who assisted you with billing and/or insurance Poor	Not ApplicableThe helpfulness of the people who assisted you with billing and/or insurance Not Applicable
The professionalism of our staff	ExcellentThe professionalism of our staff Excellent	Very GoodThe professionalism of our staff Very Good	GoodThe professionalism of our staff Good	FairThe professionalism of our staff Fair	PoorThe professionalism of our staff Poor	Not ApplicableThe professionalism of our staff Not Applicable

Name of the receptionist who assisted you: *

Name of the person who assisted you on the phone:

Name of person, if applicable, who assisted you with billing and/or insurance: *

MEDICAL ASSISTANT *

PLEASE RATE THE FOLLOWING ABOUT YOUR MEDICAL ASSISTANT

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
Willingness to listen carefully to you	ExcellentWillingness to listen carefully to you Excellent	Very GoodWillingness to listen carefully to you Very Good	GoodWillingness to listen carefully to you Good	FairWillingness to listen carefully to you Fair	PoorWillingness to listen carefully to you Poor	Not ApplicableWillingness to listen carefully to you Not Applicable
Treated you with compassion	ExcellentTreated you with compassion Excellent	Very GoodTreated you with compassion Very Good	GoodTreated you with compassion Good	FairTreated you with compassion Fair	PoorTreated you with compassion Poor	Not ApplicableTreated you with compassion Not Applicable
Demonstrated professionalism	ExcellentDemonstrated professionalism Excellent	Very GoodDemonstrated professionalism Very Good	GoodDemonstrated professionalism Good	FairDemonstrated professionalism Fair	PoorDemonstrated professionalism Poor	Not ApplicableDemonstrated professionalism Not Applicable
Concerned with your comfort and privacy	ExcellentConcerned with your comfort and privacy Excellent	Very GoodConcerned with your comfort and privacy Very Good	GoodConcerned with your comfort and privacy Good	FairConcerned with your comfort and privacy Fair	PoorConcerned with your comfort and privacy Poor	Not ApplicableConcerned with your comfort and privacy Not Applicable
Responded to your needs promptly	ExcellentResponded to your needs promptly Excellent	Very GoodResponded to your needs promptly Very Good	GoodResponded to your needs promptly Good	FairResponded to your needs promptly Fair	PoorResponded to your needs promptly Poor	Not ApplicableResponded to your needs promptly Not Applicable
Was able to answer your questions	ExcellentWas able to answer your questions Excellent	Very GoodWas able to answer your questions Very Good	GoodWas able to answer your questions Good	FairWas able to answer your questions Fair	PoorWas able to answer your questions Poor	Not ApplicableWas able to answer your questions Not Applicable

Name of Provider(s) you saw at your visit: *

PLEASE RATE THE FOLLOWING ABOUT YOUR PROVIDER(S)

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
Willingness to listen carefully to you	ExcellentWillingness to listen carefully to you Excellent	Very GoodWillingness to listen carefully to you Very Good	GoodWillingness to listen carefully to you Good	FairWillingness to listen carefully to you Fair	PoorWillingness to listen carefully to you Poor	Not ApplicableWillingness to listen carefully to you Not Applicable
Taking time to answer your questions	ExcellentTaking time to answer your questions Excellent	Very GoodTaking time to answer your questions Very Good	GoodTaking time to answer your questions Good	FairTaking time to answer your questions Fair	PoorTaking time to answer your questions Poor	Not ApplicableTaking time to answer your questions Not Applicable
Amount of time spent with you	ExcellentAmount of time spent with you Excellent	Very GoodAmount of time spent with you Very Good	GoodAmount of time spent with you Good	FairAmount of time spent with you Fair	PoorAmount of time spent with you Poor	Not ApplicableAmount of time spent with you Not Applicable
Explaining things in a way that you could understand	ExcellentExplaining things in a way that you could understand Excellent	Very GoodExplaining things in a way that you could understand Very Good	GoodExplaining things in a way that you could understand Good	FairExplaining things in a way that you could understand Fair	PoorExplaining things in a way that you could understand Poor	Not ApplicableExplaining things in a way that you could understand Not Applicable
Instructions regarding medication/follow up care	ExcellentInstructions regarding medication/follow up care Excellent	Very GoodInstructions regarding medication/follow up care Very Good	GoodInstructions regarding medication/follow up care Good	FairInstructions regarding medication/follow up care Fair	PoorInstructions regarding medication/follow up care Poor	Not ApplicableInstructions regarding medication/follow up care Not Applicable
The thoroughness of the examination	ExcellentThe thoroughness of the examination Excellent	Very GoodThe thoroughness of the examination Very Good	GoodThe thoroughness of the examination Good	FairThe thoroughness of the examination Fair	PoorThe thoroughness of the examination Poor	Not ApplicableThe thoroughness of the examination Not Applicable

PLEASE RATE THE FOLLOWING ABOUT OUR COMMUNICATION WITH YOU

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
Your phone calls getting answering promtly	ExcellentYour phone calls getting answering promtly Excellent	Very GoodYour phone calls getting answering promtly Very Good	GoodYour phone calls getting answering promtly Good	FairYour phone calls getting answering promtly Fair	PoorYour phone calls getting answering promtly Poor	Not ApplicableYour phone calls getting answering promtly Not Applicable
Getting advice or help when needed during office hours	ExcellentGetting advice or help when needed during office hours Excellent	Very GoodGetting advice or help when needed during office hours Very Good	GoodGetting advice or help when needed during office hours Good	FairGetting advice or help when needed during office hours Fair	PoorGetting advice or help when needed during office hours Poor	Not ApplicableGetting advice or help when needed during office hours Not Applicable
Your test results reported in a reasonable amount of time	ExcellentYour test results reported in a reasonable amount of time Excellent	Very GoodYour test results reported in a reasonable amount of time Very Good	GoodYour test results reported in a reasonable amount of time Good	FairYour test results reported in a reasonable amount of time Fair	PoorYour test results reported in a reasonable amount of time Poor	Not ApplicableYour test results reported in a reasonable amount of time Not Applicable
Our ability to return your calls in a timely manner	ExcellentOur ability to return your calls in a timely manner Excellent	Very GoodOur ability to return your calls in a timely manner Very Good	GoodOur ability to return your calls in a timely manner Good	FairOur ability to return your calls in a timely manner Fair	PoorOur ability to return your calls in a timely manner Poor	Not ApplicableOur ability to return your calls in a timely manner Not Applicable
Your ability to contact us after hours	ExcellentYour ability to contact us after hours Excellent	Very GoodYour ability to contact us after hours Very Good	GoodYour ability to contact us after hours Good	FairYour ability to contact us after hours Fair	PoorYour ability to contact us after hours Poor	Not ApplicableYour ability to contact us after hours Not Applicable

PLEASE RATE YOUR OVERALL SATISFACTION WITH THE FOLLOWING:

	Excellent	Very Good	Good	Fair	Poor	Not Applicable
Our practice	ExcellentOur practice Excellent	Very GoodOur practice Very Good	GoodOur practice Good	FairOur practice Fair	PoorOur practice Poor	Not ApplicableOur practice Not Applicable
The quality of your medical care	ExcellentThe quality of your medical care Excellent	Very GoodThe quality of your medical care Very Good	GoodThe quality of your medical care Good	FairThe quality of your medical care Fair	PoorThe quality of your medical care Poor	Not ApplicableThe quality of your medical care Not Applicable
Overall rating of care from the receptionist	ExcellentOverall rating of care from the receptionist Excellent	Very GoodOverall rating of care from the receptionist Very Good	GoodOverall rating of care from the receptionist Good	FairOverall rating of care from the receptionist Fair	PoorOverall rating of care from the receptionist Poor	Not ApplicableOverall rating of care from the receptionist Not Applicable
Overall rating of care from your medical assistant	ExcellentOverall rating of care from your medical assistant Excellent	Very GoodOverall rating of care from your medical assistant Very Good	GoodOverall rating of care from your medical assistant Good	FairOverall rating of care from your medical assistant Fair	PoorOverall rating of care from your medical assistant Poor	Not ApplicableOverall rating of care from your medical assistant Not Applicable
Overall rating of care from your provider	ExcellentOverall rating of care from your provider Excellent	Very GoodOverall rating of care from your provider Very Good	GoodOverall rating of care from your provider Good	FairOverall rating of care from your provider Fair	PoorOverall rating of care from your provider Poor	Not ApplicableOverall rating of care from your provider Not Applicable

Would you recommend the provider to others?

Yes
No

Do you have a specific staff member who you would like to recognize for going above and beyond and/or providing superior service? If so, please provide their name and a short description of how they helped you.

Is there any way we can improve our services to you, please tell us about it:

Layout

Patient Name (optional)

Date of Service

Email *

Resources

Treatments

Locations

Hamilton Mill

Winder

Office Hours