Survey

HOW SATISFIED ARE YOU WITH:
YOUR APPOINTMENT:	Very Satisfied	Somewhat Satisfied	Somewhat Dissatisfied	Very Dissatisfied	Not Applicable
Waiting time in the reception area
Waiting time in the exam room

OUR STAFF:	Very Satisfied	Somewhat Satisfied	Somewhat Dissatisfied	Very Dissatisfied	Not Applicable
The friendliness and courtesy of our receptionists
The caring concern of our nurses
The helpfulness of the people in our business office
The professionalism of our technical staff

YOUR VISIT WITH THE HEALTHCARE PROVIDER	Very Satisfied	Somewhat Satisfied	Somewhat Dissatisfied	Very Dissatisfied	Not Applicable
The healthcare provider listening to you
The healthcare provider taking time to answer your questions
The healthcare provider adequately explaining treatment options

YOUR VISIT TO OUR CLINIC	YES	NO
Would you use us again in the future?
Would you recommend us to friends and family?
COMMENTS: