Patient Satisfaction Survey

Patient Satisfaction Survey

We would like to know how you feel about the services we provide.  We value your input which will be used to improve our services and ensure we are meeting the needs of our patients.  Please take a moment to complete our patient satisfaction survey.  You may also fill out the pdf form and return via mail, fax or e mail at [email protected].

We thank you for your time.

Date Visited: *
Physician/Physician Assistant:
Nurse/Medical Assistant:
Radiological Tehnologist:
Patient Name:



How did you hear about our facility (check all that apply)?

Please rate the following:

Was the waiting room neat and clean?

Was the receptionist professional and courteous?

How was the wait to be seen?
Did the Nurse properly introduce themselves?

Was the Nurse professional and courteous?

Did the Provider properly introduce themselves?

Was the Provider professional and courtious?

Did the medical staff keep you informed throughout your visit?

Were your test results and planned treatment(s) explained?

Were you care instructions/questions answered?

Were you seen and treated in a timely fashion?

How would you rate your quality of care?
Please explain:
How would you rate our accessibility and convenience?
Please explain:
Would you visit our clinic again?

Would you refer us to a friend?

What did you like best about our service?
How do you feel we can improve?
May we contact you for more input?

Please enter characters: