1. Were you able to schedule an appointment that was convenient for you?
yes no
If no please explain:
2. Was the receptionist friendly and attentive?
3. When you arrived at the office, how long after your scheduled appointment did you have to wait before being seen?
less than 15 minutes 15 to 30 minutes more than 30 minutes
4. What are your expectations when you visit a physician?
5. Please rate how you perceived the physician's interest in you as a person.
seemed interested and concerned usually seemed interested and concerned sometimes seemed indifferent never seemed to have enough time
6. Please rate how you perceived the nurse's interest in you as a person.
7. Please rate how you perceived the technicians's interest in you as a person.
seemed interested and concerned usually seemed interested and concerned sometimes seemed indifferent never seemed to have enough time not applicable
8. During your visit, do you believe you were give an adequate explanation of your illness or medical condition, medications and other treatment recommendations?
If no, how could this have been improved?
9. Were your questions answered adequately?
10. Did you receive adequate assistance from the billing office?
yes no not applicable
If no, please explain:
11. Please rate the appearance of the facility.
excellent good fair poor
12. How well do you like the Center's hours?
fine as they are would like to see later hours would be better if they were:
13. Please evaluate YOURSELF for:
a. taking your prescribed medications
always take usually take sometimes take rarely take
b. following the physician's or nurse's advice
always usually sometimes rarely
14. How did you first hear about the Center?
physician referred me family friend radio newspaper other:
15. Overall, how would you consider your experience at the Center?
16. I would recommend this practice to my friends and family.
We welcome and encourage any additional comments you may have. All comments, whether positive or negative, are appreciated.
Name/Number - Should you require a returned phone call to discuss this matter (optional) :
Physician (optional):
