Were you able to make contact with our office in a timely manner? Yes No
Was the scheduling process time: About what was expected Longer than expected Shorter than expected
Was the receptionist friendly and helpful to you? Yes No
Ease of Scheduling Process? 1. Poor 2. Below Average 3. Average 4. Good 5. Great
Did the receptionist provide your patient a timely appointment date/time? Yes No
Rank the staffs' response time to any inquiries you may have had. 1. Poor 2. Below Average 3. Average 4. Good 5. Great
Rank the staffs' overall care of your patient. 1. Poor 2. Below Average 3. Average 4. Good 5. Great
Did you receive your patient's results in a timely manner? Yes No
Are you happy with the quality of care your patient has received at our facility? Yes No
Is there anything we could change to better serve you?
Would your recommend our facility to your patients? (if no, why?) Yes No If you selected (No) please indicate why in the field below
Name *** You may remain anonymous by leaving this question blank
May we contact you to discuss your feedback? Yes No
Additional Notes/Comments
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