Patient Survey

"*" indicates required fields

What is the name of your Provider?*

How many years have you been a patient of this practice?*

How do you feel about the following statements?*

	Strongly Disagree	Disagree	Neutral	Agree	Strongly agree
It is Easy to make an appointment for a checkup.
It is easy to make an appointment when I am sick.
The receptionists were helpful, courteous and respectful.
The receptionists / office staff was helped me to understand my insurance.
The nursing staff was helpful and courteous to me.
My provider knows the best way to treat my problem.
I had enough time with my Provider.
I understood what my Provider told me.
My Provider treated me like a person, not just another case.
I received what I came for during my current or most recent visit.
The office is open hours that are convenient for me.
Overall, I am satisfied with the care I receive.

If you disagree with our office hours, please specify the days and times that are best for you.

Would you recommend your Provider to a friend?*

Yes, definitely!

Maybe

No

Please select the amount of time it took for you to be seen for your last scheduled appointment.*

On time.

Within 5 minutes.

Within 10 minutes.

Within 15 minutes

Within 20 minutes.

Within 30 minutes.

Within 40 minutes.

Comments

Please take a few moments to tell us what you think of that care you have received from your Provider

Email

Phone

This field is for validation purposes and should be left unchanged.