Patient Satisfaction Survey

YOUR CONTACT INFORMATION:

Name:

Email Address:

Telephone Number:

STAFF RATINGS
On a scale of 1-10 (10 being best), please choose appropriate:

APPOINTMENT STAFF RATING:
.

Ease of scheduling your Appointment:

Friendliness of Appointment Staff:

Overall Professionalism of Appointment Staff:

CHECK-IN/CHECK-OUT STAFF RATING:
.

Receptionist treated me with courtesy & respect:

Friendliness of our Check-in/Check-out Staff:

Overall Professionalism of our Check-in/Check-out Staff:

Lobby Wait Time:

CLINICAL STAFF RATING:
.

Name of your Physician:

Friendliness of Physician:

Friendliness of Medical Assistant:

Treatment was explained to me in an easy to understand way:

Did the Clinical Staff follow-up with you in a timely manner?

Overall Professionalism of Clinical Staff:

SURVEY RESPONSE:

May CARE FOR WOMEN Management contact you to discuss this survey?

How would you like us to contact you?

ADDITIONAL COMMENTS:

Please type any additional comments about your experience at CARE FOR WOMEN:

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