Patient Satisfaction Survey
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1PATIENT SATISFACTION SURVEY
Dear Patients:
In an effort to improve our service, we are conducting a patient survey. Please take a moment to complete this
questionnaire to enable us to better serve you.
How long have you been a patient of our practice?
First year
1-5 years
5-10 years
Over 10 years
Why did you decide to seek medical treatment with us?
Near home or business
Telephone listing
Referral by another patient
Other: _________________________________________________
Referral by another physician
Was making an appointment a simple process?
Yes
No
If no, please explain: ___________________________
_________________________________________________________________________________________________
How would you rate the telephone service of our practice?
Very Good
Good
Average
Poor
Very Poor
Once in our office, did the receptionist treat you in a friendly, courteous manner?
Yes
No If no, please explain:
______________________________________________________________________________________________
How long did you wait in the reception area after your appointment time?
Less than 15 minutes
15 to 30 minutes
More than 30 minutes
Name of physician that you routinely see in the office:
_____________________________________________________________
Does the physician provide you with adequate time for each visit?
Yes
No
If no, please explain:
__________________________________________________________________________________________________
Does the physician explain your problem and treatment plan?
Yes
No
Does the physician explain why he/she does or does not order certain medications or tests?
Always
Sometimes
Never
Was the medical assistant helpful and courteous?
Yes
No
If no, please explain: ______________________
__________________________________________________________________________________________________
Was the billing office helpful and courteous?
Yes
No
If no, please explain: __________________________
__________________________________________________________________________________________________
What was your impression of the physical office? (check all that apply)
Beautiful
Nice
Average
Shabby
Organized
Disorganized
A Total Mess
Was the reception area comfortable?
Yes
No If no, please explain: __________________________________
_________________________________________________________________________________________________
Our staff is committed to continually improving the services we provide to all patients. We invite you to use the space on
the back of this survey to give us suggestions on how we can improve our service. Your comments are most valuable and
we appreciate your time.
Please provide your name below if you would like to be contacted about any problem(s) you have experienced. Thank you
________________________________________________
_________________
_________________________
Patient Name
Date
Contact Phone Number
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Parent category: Life