Online Survey Form
Doctor Name*
* Required field

Please rate your level of satisfaction by selecting your answers below:
5=Very Satisfied, 4=Satisfied, 3=Unsatisfied, 2=Extremely Unsatisfied, 1=No Opinion,
Scheduling
1. The convenience of scheduling the appointment 5 4 3 2 1
2. The adequacy of the instructions about how to prepare for your appointment 5 4 3 2 1
3. The courtesy and efficiency of the scheduling staff 5 4 3 2 1
4. Your overall level of satisfaction with the scheduling process 5 4 3 2 1

Registration
1.The courtesy and efficiency of the receptionist 5 4 3 2 1
2.The comfort and appearance of the waiting room 5 4 3 2 1
3.Your overall level of satisfaction with the registration process 5 4 3 2 1

Your Appointment
1. Did you have to wait past your scheduled appointment time? No Yes Don't Know
2. Approximately how long was your wait?
Taken Early No Wait 1-15 mins 16-30 mins 31+ mins
3. Your overall Satisfaction with the waiting time 5 4 3 2 1
4. The nurse's sensitivity and ability to communicate 5 4 3 2 1
5. Respect for your privacy 5 4 3 2 1
6. The comfort and appearance of the exam room 5 4 3 2 1
7. Your overall level of satisfaction with your appointment 5 4 3 2 1

Would you recommend our practice to a friend or relative? Yes No Don't Know

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