Patient Satisfaction Survey Template
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2Patient Satisfaction Survey
At SightLine, we work hard to provide our patients with the highest quality care possible. We want to
ensure that we are doing everything possible to serve you. Your opinion, and the feedback you
provide, allows us to identify ways in which we can improve, and helps us know what it is we are
doing right. Please take a minute to fill out the confidential survey below.
Questions marked with a * are required.
1.
Patient Name (Optional): ______________________________________
*2. Site of Service: _____________________________________________
The questions below are rated from 1 to 5:
1 = STRONGLY
4 = AGREE
DISAGREE
5 = STRONGLY
2 = DISAGREE
AGREE
3 = NEUTRAL
cir
Please read each question carefully and
your response. Each completed survey is reviewed with
e
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our clinical staff.
*3. Ease of Access to Care
The facility was easy to locate.
1
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3
4
5
The facility was easy to access.
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2
3
4
5
Parking at the facility is convenient and adequate.
1
2
3
4
5
Hours of operation meet your needs.
1
2
3
4
5
Our staff returned your messages promptly.
1
2
3
4
5
Any time spent waiting to be seen was brief, and you were
comfortable.
1
2
3
4
5
The receptionist was friendly and courteous.
1
2
3
4
5
The registration process was easy and efficient.
1
2
3
4
5
*4. Clinical Staff
The clinical staff was courteous and empathetic.
1
2
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4
5
The knowledge and skill of our clinical staff was excellent.
1
2
3
4
5
The clinical staff worked well together as a team.
1
2
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5
The clinical staff was sensitive to your needs.
1
2
3
4
5
The clinical staff was concerned about your comfort.
1
2
3
4
5
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Parent category: Life