Patient Survey

	Excellent	Good	Fair	Poor	n/a
1. Overall experience
2. Courtesy of staff
3. Ease of registration
4. Comfort of waiting area
5. Comfort of exam room
6. Accessibility of location and office
7. Promptness of service
8. Friendliness and courteousness of receptionist
9. Caring attitude of medical assistant
10. Experience with your physician
11. Time between making appointment and being seen
12. Which physician did you see for your appointment?
13. Suggestions/Comments on how we can improve our service:
14. Would you recommend our office to a friend or relative?		Yes: No:
15. If no, please provide additional details:
16. Additional comments:
Name:
Address:
Email Address:
I would like to speak with your Patient Relations Representative. My phone number is:
Date of patient visit: