Patient Satisfaction Survey Patient Survey Form Provider’s Name Date of Visit * Age (optional) How long did you wait in reception before you were called into the exam room? How long did you wait in an exam room before your were seen by your doctor or midwife? Office Location * Beverly Gloucester Danvers Is this your first visit to the practice? * Yes No Access To Care Ease of scheduling your appointment Excellent Very Good Good Fair Poor Courtesy of call nurse, if you spoke with one Excellent Very Good Good Fair Poor Courtesy of person who scheduled your appointment Excellent Very Good Good Fair Poor During Your Visit Courtesy of Staff in the Registration Area Excellent Very Good Good Fair Poor Atmosphere & Level of Comfort in the Waiting Area Excellent Very Good Good Fair Poor Length of Wait Before Going to an Exam Room Excellent Very Good Good Fair Poor Comfort & Pleasantness in the Exam Room Excellent Very Good Good Fair Poor Friendliness / Courtesy of the Nurse / Assistant Excellent Very Good Good Fair Poor Waiting Time in the Exam Room Before Being Seen by the Provider Excellent Very Good Good Fair Poor Your Care Provider Friendliness / Courtesy of the Care Provider Excellent Very Good Good Fair Poor Amount of Time the Care Provider Spent With You Excellent Very Good Good Fair Poor Your Confidence in this Care Provider Excellent Very Good Good Fair Poor Likelihood of Your Recommending this Care Provider to Others Excellent Very Good Good Fair Poor Our Facility Hours of Operation Convenient for You Excellent Very Good Good Fair Poor Overall Comfort of Your Visits Excellent Very Good Good Fair Poor Adequate Parking Excellent Very Good Good Fair Poor Signage & Directions Easy to Follow Excellent Very Good Good Fair Poor Overall Assessment Our Sensitivity to Your Needs Excellent Very Good Good Fair Poor Overall Cheerfulness of Our Practice Excellent Very Good Good Fair Poor Overall Cleanliness of Our Practice Excellent Very Good Good Fair Poor Overall Rating of Care Received During Your Visit Excellent Very Good Good Fair Poor Likelihood of Your Recommending Our Practice to Others Excellent Very Good Good Fair Poor Question/Comments If you are human, leave this field blank. SUBMIT FORM
