Patient Survey

General Information

How would you rate the service you received? Select optionOutstandingGoodSome issuesPoor

How easy was it to make an appointment? Select optionVery easyAverageVery difficult

Was the person who scheduled your appointment courteous and helpful? Select optionOutstandingGoodSome issues

How would you rate the courtesy of the staff at the reception desk? Select optionVery courteousAverageRude

How long did you wait beyond your scheduled appointment time? Select option0-15 minutes15-20 minutes20-40 minutesmore than 40 minutes

How would you rate the nurse who helped you? Select optionVery courteousAverageRude

Did the nurse respond to your requests within a reasonable period? Select optionYesNo

Comments:

The Doctor or Physical Therapist

Were you able to see the doctor of your choice? Select optionYesNoN/A

Which doctor did you see? Select optionDr. MarcianoDr. AmelungDr. YeargainDr. SuttlePhysical Therapist

How would you rate your doctor? Select optionOutstandingGoodSome issuesPoor

Please rate the clarity of the doctor’s explanation of your condition and treatment options:Select optionOutstandingGoodSome issuesPoor

Comments:

Were your questions answered to your satisfaction? Select optionYesNoN/A

Would you recommend this facility and its staff to your family and friends? Select optionYesNo

Comments: Please list any areas in which our service could be improved and share any additional comments.

Personal Information

Name:

Email Address:

Phone Number:

Would you recommend this facility and its staff to your family and friends? Select optionYesNo

Thank you for taking the time to fill out our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated.