About Us Patient Survey Your Name Date of Your Visit Was the scheduler helpful in making your appointment? YesNoDoes Not Apply Did you get the appointment of your choice? YesNoDoes Not Apply Was the scheduler friendly, warm and caring? YesNoDoes Not Apply Were you greeted warmly by the receptionist in a timely manner? YesNoDoes Not Apply Did the receptionist explain the forms and how you needed to fill them out? YesNoDoes Not Apply Was your wait time acceptable in the waiting room? YesNoDoes Not Apply Were any delays explained? YesNoDoes Not Apply Did the nursing staff introduce themselves? YesNoDoes Not Apply Did the nursing staff explain what they were doing and why? YesNoDoes Not Apply Was the nursing staff friendly, warm and caring? YesNoDoes Not Apply Did you find your wait time acceptable in the exam room? YesNoDoes Not Apply Did your provider (doctor or nurse practitioner) spend enough time with you? YesNoDoes Not Apply Did your provider (doctor or nurse practitioner) answer all of your questions? YesNoDoes Not Apply Was the front office staff helpful in making any return appointment you needed to schedule? YesNoDoes Not Apply Would you recommend this office to your friends or family members? YesNoDoes Not Apply Overall, were you satisfied with your visit today? YesNoDoes Not Apply Why? Were you happy with any staff member today? YesNoDoes Not Apply Why? Were you dissatisfied with any staff member today? YesNoDoes Not Apply Why? Additional Comments or Suggestions:
