Appointment Satisfaction Survey

Please complete the following survey to describe your level of satisfaction with your recent office visit. When you have completed the survey, press the Submit button to send us your response. All submissions will be kept strictly confidential.

Please answer the five Yes/No questions. If any answers are no, please explain in the Explanation & Comments box below.

1. Were you satisfied with the care you received during your visit?
YesNoN/A

2. Given the number of patients waiting for treatment at the time of your visit, do you feel the time you spent waiting was appropriate?
YesNoN/A

3. If staff was busy, and you were required to wait, was an explanation given to you by the staff? YesNoN/A

4. Was the environment clean and comfortable? YesNoN/A

5. Was the office / surgery center convenient? YesNoN/A

6. What did you like most about our facility?

7. What did you like least about our facility?

8. Do you have any suggestions that would help us to improve our services?

Evaluate Our Staff: 5=Excellent 4=Very Good 3=Good 2=Not Good 1=Bad

Secretaries (Check In & Check Out): 54321

Medical Tech: 54321

Scheduling (surgical procedures): 54321

Billing: 54321

Nurses: 54321

Anesthesia Provider: 54321

Enter the date of your visit:

Office Location (select one):
Forest HillHavre De GraceSurgery Center

Explanation &/or comments

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