PATIENT SATISFACTION SURVEY

Section A: Your Appointment

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Ease of scheduling appointments by phone (*)
54321N/A

Appointment available within a reasonable amount of time (*)
54321N/A

Receiving care for illness/injury as soon as you wanted it (*)
54321N/A

Efficiency of the check-in process (*)
54321N/A

Waiting time in the reception area (*)
54321N/A

Waiting time in the exam room (*)
54321N/A

Keeping you informed of any delays in your appointment time (*)
54321N/A

Ease of getting a referral when you needed one (*)
54321N/A

Section B: Our Staff

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

The courtesy of the person who took your call (*)
54321N/A

The friendliness and courtesy of the receptionist (*)
54321N/A

The concern of our medical assistants (*)
54321N/A

The helpfulness of the people assisting you with billing or insurance (*)
54321N/A

Section C: Our Communication With You

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Your phone calls being answered promptly (*)
54321N/A

Getting advice or help when needed during office hours (*)
54321N/A

Explanation of your procedure (if applicable)
54321N/A

Your test results reported in a reasonable amount of time (*)
54321N/A

Effectiveness of our health information materials (*)
54321N/A

Our ability to return your calls in a timely manner (*)
54321N/A

Your ability to contact us after hours (*)
54321N/A

Your ability to obtain prescription refills by phone (*)
54321N/A

Section D: Your Visit With the Provider: (Dr., Physician, Nurse Practitioner)

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Willingness to listen carefully to you (*)
54321N/A

Taking time to answer your questions (*)
54321N/A

Amount of time spent with you (*)
54321N/A

Explaining things in a way you could understand (*)
54321N/A

Instructions regarding medication/follow-up care (*)
54321N/A

Thoroughness of the examination (*)
54321N/A

Advice given to you on ways to stay healthy (*)
54321N/A

Section E: Our Facility

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Hours of Operation convenient for you? (*)
54321N/A

Overall comfort (*)
54321N/A

Adequate parking (*)
54321N/A

Signage and directions easy to follow (*)
54321N/A

Section F: Your Overall Satisfaction

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Our Practice (*)
54321N/A

The quality of your medical care (*)
54321N/A

The quality of your medical care (*)
54321N/A

Would you recommend Northwest Eye Surgeons to others?
YesNo

If NO, please tell us why:

If there is any way we can improve our services to you, please tell us about it:

Some information about you

For the following 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor.

Gender
MaleFemaleN/A

Your Age
Under 1818-3031-4041-5051-60Over 60N/A

Are you?
A New PatientA Returning PatientN/A

Please provide your name if you would like to further discuss how we can continue to better your experience:

Thank you for your feedback!