1. Is this a FIRST visit or RETURN visit? *
2. Why did you choose this office for your medical treatment? (Please check one) *
3. How long did it take you to get in for your initial appointment? (please check one) *
4. Was this timeframe acceptable to you? *
5. Please describe initial telephone call experience? *

Provider Survey (Scale 1-5)

6. Please rate the nurse/medical assistant: 
7. How was the attitude of the office staff? *
8. Were you satisfied with the amount of time the doctor spent with you? *
9. How comfortable did you find the waiting room? *
10. If applicable, rate your experience contacting us after hours?
11. How would you rate your check-out experience? *
12. Please rate your physician's interest in your problem? *
13. How would you rate the helpfulness of the individual helping with billing and/ or insurance? *
14. Were you satisfied with the medical treatment you received? *
15. If any x-ray or procedures were performed, how would you rate your experience?
16. How would you rate our automated telephone system? *
17. Did we provide you with helpful patient educational information? *
18. If you received Durable Medical Equipment (braces or slings), did you receive adequate explanation of your options, cost, fitting?
20. If the physician was running behind, did the staff explain this to you? *
21. If it was required, did you receive adequate assistance in completion of any needed forms?
22. Were your test results reported in a reasonable amount of time? *
23. Did we return your call in a reasonable amount of time? *
24. Would you refer a family member or friend? *
24. Would you refer a family member or friend? *
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