Patient Satisfaction Survey

Was this your first visit to our office?
—Please choose an option—YesNo

If this was your first visit how did you hear about us?

What was the purpose of your visit?

Ease of setting your appointment
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Greeting by our receptionist when you arrived
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Cleanliness/ neatness of the waiting room
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Cleanliness/neatness of the procedure suite
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Length of time you had to wait before you called for your appointment
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Friendliness of our office staff
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Friendliness of the physician
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Ability of physician to put you at ease
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Quality of the service performed
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Degree to which your concerns were addressed by either the technician or the physician
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The ease of checking out and paying after the appointment
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How likely is it that you would recommend our office to your family members, co-workers, and friends?
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In your own words, let us know any positive experiences you had or issues or concerns you may have about our services o practices and procedures

Would you like to provide us with your contact information?