Please read the following sentences, then choose whether you agree or disagree

1. The person I spoke with on the phone was helpful and courteous

   • agree
   • disagree

2. The number of days I had to wait to get an appointment was excessive

   • agree
   • disagree

3. The receptionist who greeted me was helpful and courteous

   • agree
   • disagree

4. The length of time I waited in the reception area was excessive

   • agree
   • disagree

5. The length of time I waited in the exam room was excessive

   • agree
   • disagree

6. The amount of time the physician spent with me answering my questions was adequate for my needs

   • agree
   • disagree

7. The physician treated me with dignity and respect

   • agree
   • disagree

8. The appearance of the office/exam rooms was clean and pleasant

   • agree
   • disagree

9. I am pleased with the quality of care I received from the physician

   • agree
   • disagree

1. Is your privacy maintained during your visit?

   Yes, most definitely No, my conversation can be heard by others I am embarrassed to discuss my problems because of the lack of privacy

2. How are you generally treated by the staff during your visits?

   Like a good friend Nicely Adequately Rudely

3. When you leave the office, do you feel you have adequate information concerning the state of your health or condition?

   • Everything is explained exceptional well, including procedure preparation and what to expect
   • I feel well informed
   • Everything is adequately explained
   • I feel a bit baffled but do not feel comfortable asking questions
   • I feel a bit baffled but the staff did not have the time to answer my questions
   • I feel totally confused and frustrated

4. Do you understand what your financial responsibility to the practice is?

   • I have been informed on the phone prior to my visit what my responsibility is
   • I didn't realize that I would be required to pay anything at the time of my visit
   • I understand my obligation and my insurance company's obligation
   • Everything is explained thoroughly during my visit

5. What would make your experience with us more pleasant?

   Please leave your comments here... Do not leave any personally identifying information!

6. If a friend needed the services we provide, would you recommend us?

   • yes
   • no