● Patient Satisfaction Survey
Dear Patient,
We are delighted to have you as a patient and want to do our very best in assisting you with your child's healthcare. As we work towards assuring the most pleasant experience possible, it is imperative to hear your comments and suggestions to enable us in improving our weaknesses. We value your comments and thank you in advance for taking the time to complete this questionnaire.
● Please click on the option button in front of the best answer to each
question. So that we get a complete picture of your experience, we really
need your answers to all questions.
● Please click N/A if a question is Not Applicable to you.
● You can change your mind and click a different button for any question.
● Feel free to make as many comments as you deem necessary.
►Please Note:
● DO NOT include any personal contact information, insurance information,
or Social Security numbers on this non-secure form.
● DO NOT include any subject related to patient care that should only be
discussed with a doctor or staff either in-person or on the phone.
Thank you for your valuable input.
Let's begin!
_______________________________________________
Not Likely Probably Absolutely
►Likelihood of recommending our practice to others
Scheduling of Appointments: Poor Fair Good Exceptional N/A
►Length of time to reach us for a Well Appointment
►Courtesy of Well Appointment scheduler
►Length of time to reach us for a Sick Appointment
►Courtesy of Sick Appointment scheduler
►Appointment time availability to see child
in a timely manner
►Helpfulness of Sick Appointment scheduler
►Additional Comments:
Receptionists upon Arrival/Departure: Poor Fair Good Exceptional N/A
►Your greeting and efficiency upon check-in
►Your greeting and efficiency upon check-out
►Courtesy and personal attention to your needs
from the receptionists
Your Appointment: Poor Fair Good Exceptional N/A
►Convenience of appointment time
►Pleasantness of wait
►Time waiting in reception area
►Pleasantness and comfort of exam room
►How long did you wait in the reception area?
►What was the time of your appointment?
Your Nurse: Poor Fair Good Exceptional N/A
►Friendliness
►Considerate of your needs / concerns
►Compassionate / Caring
Your Doctor: Poor Fair Good Exceptional N/A
►Length of time spent with doctor
►Doctor's efforts to include you in decisions
concerning treatment options
►Your confidence in this doctor
►Doctor seen today: Salvatore Anzalone Sandra Weidner Ruth Spillerman
Rebecca Ezard Robert Cordes Timothy Tam
Miscellaneous: Poor Fair Good Exceptional N/A
►Comfort in office
►Cleanliness of office
►Cleanliness of exam room
►Personal attention received
►Parking
►Convenience of office hours
►Our sensitivity to your needs
►Overall cheerfulness of the staff
►Overall rating of care you received
►How did you hear about our office?
►Most convenient time(s) for appointments:
(You may click more than one choice)
Morning - Yes No
Afternoon - Yes No
Evening - Yes No
►Any other suggestions or additional comments for us to consider:
We thank you for your trust and the opportunity to assist you
in your child/children's healthcare!
Name (Optional):
Date (Optional):
● Please review this form to make sure that an answer was given for every
question.
● Then press the Submit button below, and this form will be sent to us.
Thanks again for your time and effort to help us improve our service to you and all other patients!
