HOW ARE WE DOING????

Instructions: Please rate the service you received from our practice.  Select the response that best describes your experience.  If a question does not apply to you, please skip to the next question. There is also space provided for your questions, concerns, or comments.

BACKGROUND QUESTIONS

* 1. Are you currently being seen or have you been seen in our office?
Yes
No
* 2. Was this your first visit?
Yes
No
* 3. How many minutes did you wait after your first scheduled appointment time before you were called to an exam room?
* 4. How many minutes did you wait in the exam room before you were seen by a Doctor?

ACCESS

Please Rate on a scale of 1-5: 1-Very Poor, 2-Poor, 3-Fair, 4-Good, 5-Very Good

1. Ease of getting through to the clinic on the phone?
2. Our helpfulness on the telephone?
3. Our promptness on the telephone?
4. Convenience of our office hours?
5. Ease of scheduling your appointment?
6. Courtesy of person who scheduled your appointment?
7. Courtesy of staff in the reception area?
8. Courtesy in the therapist area?

MOVING THROUGH YOUR VISIT

Please Rate on a scale of 1-5: 1-Very Poor, 2-Poor, 3-Fair, 4-Good, 5-Very Good

1. Degree to which you were informed about any delays?
2. Wait time at clinic from arriving to leaving?
3. Speed of the registration process?
4. Length of wait time before going to exam room?
5. Waiting time in exam room before being seen by a Doctor?

STAFF

1. Did the staff make you feel welcomed?
2. Friendliness of the staff?

CARE PROVIDER

During your visit, your care was provided by a Doctor and Therapist.  Please answer the following questions with that health care provider in mind.  Please rate on a scale of 1-5; 1-Very poor, 2-Poor, 3-Fair, 4-Good, 5-Very good.

1. Friendliness/courtesy of the care provider.
2. Explanations the care provider gave you about your problem or condition.
3. Concern the care provider showed for your questions or worries.
4. Care provider's efforts to include you in decisions about your treatments.
5. Instructions the care provider gave you about follow-up care (if any).
6. Degree to which care provider talked with you using words you could understand.
7. Amount of time the care provider spent with you.
8. Your confidence in this care provider.
9. Likelihood of your recommending this care provider to others.

BILLING PROCESS

1. Courtesy of insurance/billing personnel.
2. Clarity of billing/insurance coverage.
3. Promptness with which questions or problems about your bill were resolved (if you had any).
4. Handling of insurance/billing questions.
5. Clarity of billing statements/questions.

PERSONAL ISSUES

1. How well staff protected your safety (by washing hands, wearing gloves, etc).
2. Our sensitivity to your needs.
3. Our concern for your privacy.
4. Cleanliness of our practice.
5. Likelihood that we greeted you with a smile.
6. Ease of obtaining referrals for specialty care.

OVERALL ASSESSMENT

1. How well the staff worked together to care for you.
2. Likeliness of your recommending our practice to others.
3. Overall rating of the staff's introduction of themselves.
Comments:
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* Preferred Contact Method?
Telephone
Email
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