Patient Satisfaction Survey

Please fill out entirely:

1

How would you rate the helpfulness of our staff upon your first phone call in?
 
Excellent
Good
Fair
Poor
I Don't Know

2

When you came for your appointment, how long did you have to wait before you were seen by someone?
 
5-10 Minutes
11-20 Minutes
21-30 Minutes
More than 30 Minutes

3

How satisfied were you with the way you were treated by the doctor?
 
Very Satisfied
Somewhat Satisfied
No Opinion
Somewhat Dissatisfied
Very Dissatisfied

4

How satisfied were you with the quality of your care?
 
Very Satisfied
Somewhat Satisfied
No Opinion
Somewhat Dissatisfied
Very Dissatisfied

5

How would you rate the courtesy you were shown by our staff at the Center?
 
Excellent
Good
Fair
Poor
I Don't Know

6

My questions were answered.
 
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree

7

My visit to the Center was a pleasant experience.
 
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree

8

What are we doing especially well?
 

9

What can we do to improve?
 

10

I'd like to refer a friend to be a patient at Clear Choice:
 
Name
Email