Patient Satisfaction Survey Template printable pdf download

Patient Satisfaction Survey Template

Name: ………………………………………………..

Date: ………………………

Patient Satisfaction Survey

Thank you for staying at a MedPrime Sleep Center. Quality sleep diagnostic testing and

therapeutic evaluation is very important to us. We ask that you take a moment and answer the

following questions so that we may continue to improve our patient care.

1. Did you receive a call prior to your sleep study from a Staff member which went over

instructions about your visit within a reasonable amount of time?

Yes ____ No ____

2. Was your appointment scheduled within a reasonable

Yes ____ No ____

amount of time?

3. Did your technologist take the time to answer all questions?

Yes ____ No ____

On a scale of 1 to 5, with 1 being very dissatisfied and 5 being very satisfied, please rate us on

the following statements:

1. Quality of Room (Clean and Comfortable)

2. Friendliness of Staff

3. Treatment by Staff was friendly and professional

4. Peaceful environment with no outside interruptions or noise

5. Overall service of sleep lab

6. What was your technologist’s name? ____________________________________________

7. My sleep study was performed on (day/date) ____________________________________

Please list any other comments or suggestions that you have to help us improve our patient care.

_____________________________________________________________________________

If you have any other questions, concerns, or compliment’s that you feel that you are not able to convey

on this form, please feel free to contact our (Insert your info).

Patient Satisfaction Survey Template