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