subject_line
What is today's date?
*
+
Who is your provider?
*
Dr. Wathne
Dr. Blair
Dr. Joseph
Dr. Bray
Boe Simmons, PA-C
Justing Pool, PA-C
1. Is this a
FIRST
visit or
RETURN
visit?
*
First
Return
2. Why did you choose this office for your medical treatment? (Please check one)
*
Near my office or home
Referred by another patient
Referred by the Emergency Dept.
Telephone listing
Referred by another physician(please print name below)
Picked from my insurance plan physician listing
Other (please specify)
Physician Name (print) or Other (specify)
*
3. How long did it take you to get in for your initial appointment? (please check one)
*
Less than 1 week
1-2 weeks
3-4 weeks
5-6 weeks
Greater than 6 weeks
4. Was this timeframe acceptable to you?
*
Yes
No
5. Please describe initial telephone call experience?
*
Positive
Negative
N/A
If negative, please explain why?
Provider Survey (Scale 1-5)
6. Please rate the nurse/medical assistant:
Name (if Known):
*
*
1 Personable
2
3
4
5 Disinterested
7. How was the attitude of the office staff?
*
1 Friendly
2
3
4
5 Cold
8. Were you satisfied with the amount of time the doctor spent with you?
*
1 Very Satisfied
2
3
4
5 Very Dissatisfied
9. How comfortable did you find the waiting room?
*
1Very Comfortable
2
3
4
5 Very Uncomfortable
10. If applicable, rate your experience contacting us after hours?
1 Very Satisfied
2
3
4
5 Very Dissatisfied
11. How would you rate your check-out experience?
*
1 Pleasant
2
3
4
5 Unpleasant
12. Please rate your physician's interest in your problem?
*
1 Interested
2
3
4
5 Indifferent
13. How would you rate the helpfulness of the individual helping with billing and/ or insurance?
*
1 Pleasant
2
3
4
5 Unpleasant
14. Were you satisfied with the medical treatment you received?
*
1 Very Satisfied
2
3
4
5 Very Dissatisfied
15. If any x-ray or procedures were performed, how would you rate your experience?
1 Very Satisfied
2
3
4
5 Very Dissatisfied
16. How would you rate our automated telephone system?
*
1 Easy to Use
2
3
4
5 Very Complicated
17. Did we provide you with helpful patient educational information?
*
Yes
No
N/A
18. If you received Durable Medical Equipment (braces or slings), did you receive adequate explanation of your options, cost, fitting?
Yes
No
N/A
20. If the physician was running behind, did the staff explain this to you?
*
Yes
No
N/A
21. If it was required, did you receive adequate assistance in completion of any needed forms?
Yes
No
N/A
22. Were your test results reported in a reasonable amount of time?
*
Yes
No
N/A
23. Did we return your call in a reasonable amount of time?
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Yes
No
N/A
24. Would you refer a family member or friend?
*
Yes
No
N/A
24. Would you refer a family member or friend?
*
Yes
No
N/A
Name (optional)
Telephone Number (optional)
Additional Comments:
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