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Dear Patient,

It is our desire to provide you with the finest medical care in a courteous and friendly, yet efficient atmosphere, both in the office and the hospital. To help us live up to this goal, we ask your assistance in filling out this questionnaire. Your comments are sincerely appreciated and are extremely helpful.

Thank You!

Reception & Appointments
Courtesy		Super Good Fair Poor
Promptness		Super Good Fair Poor
Helpfulness		Super Good Fair Poor
Efficiency		Super Good Fair Poor
Reception Staff
Courtesy		Super Good Fair Poor
Promptness		Super Good Fair Poor
Helpfulness		Super Good Fair Poor
Efficiency		Super Good Fair Poor
Telephone & Switchboard
Courtesy		Super Good Fair Poor
Promptness		Super Good Fair Poor
Helpfulness		Super Good Fair Poor
Efficiency		Super Good Fair Poor
Nursing & Clinical Staff
Courtesy		Super Good Fair Poor
Promptness		Super Good Fair Poor
Helpfulness		Super Good Fair Poor
Efficiency		Super Good Fair Poor
Facilities
Atmosphere		Super Good Fair Poor
Comfort		Super Good Fair Poor
Convenience		Super Good Fair Poor
Parking		Super Good Fair Poor
Insurance Department
Courtesy		Super Good Fair Poor
Promptness		Super Good Fair Poor
Helpfulness		Super Good Fair Poor
Efficiency		Super Good Fair Poor
About Your Physician
Did your Doctor make clear to you the nature of your illness and the treatment prescribed?  Yes No
Your Doctor was...		Super Good Fair Poor
If you have ever contacted your Doctor after hours, how was your experience?  Prompt Contact Delayed Contact Never Contacted Super Good Fair Poor
What did you like best about your relationship with your Doctor and/or our staff?
What could we change to improve the quality of future visits?
If you have any additional comments or suggestions, please enter them below:

Thank you for taking the time to fill in our questionnaire!

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