Patient Satisfaction Survey
Why did you seek treatment in this office
Near home or business
Physician Referral Service
Referral by another patient
Referred by Medical Society
Telephone Directory Listing
Web Site
Other
Was it easy to get an appointment?
Yes
No
When you last visited our office, you were treated how?
Royally
Courteously
Poorly
Upon arrival at our office, how long after your scheduled appointment do you usually have to wait to be seen?
Less then 15 minutes
15 to 30 minutes
30 to 45 minutes
Over 45 minutes
During your last visit, how where you treated by our staff?
Royally
Courteously
Poorly
Please rate your perception of the interest we take in you as an individual?
Always intersted and concerned
Usually interested and concerned
Sometimes seem indifferent
Never appear to have enough time
Please elaborate
Are you satisfied with the medical treatment you received from us?
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Additional comments?
Additional Comments
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Name
E-mail
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