Patient Satisfaction Survey


In order for our site to continuously improve the quality of care provided to our patients, please take a few minutes to complete the following brief questionnaire.

Note: This survey will be submitted to us anonymously if your contact information is omitted.

Please answer the following questions by choosing the appropriate response as follows:

1 – Not Applicable
2 – Not at all satisfied
3 – Somewhat satisfied
4 – Satisfied
5 – Very satisfied
6 – Completely satisfied


1. When you telephoned our office, was our staff courteous and friendly?
1 2 3 4 5 6

2. Was the time it took for us to answer your call satisfactory?
1 2 3 4 5 6

3. Was the time between your call to schedule an appointment and your appointment date satisfactory? (Did we fit you in fast enough?)
1 2 3 4 5 6

4. When you arrived for your scheduled appointment were our reception area personnel courteous and helpful?
1 2 3 4 5 6

5. Was our reception area comfortable and did it offer adequate reading/viewing materials?
1 2 3 4 5 6

6. Was your exam performed in accordance with your scheduled appointment?
1 2 3 4 5 6

7. Was the exam room clean and did it offer sufficient privacy?
1 2 3 4 5 6

8. Were our technologists caring and professional?
1 2 3 4 5 6

9. Was the procedure explained to you and were your questions answered?
1 2 3 4 5 6

10. Was the nursing staff understanding and caring?
1 2 3 4 5 6

11. Would you recommend our facility to a family member or a friend?
1 2 3 4 5 6

 

Optional--Please note this form will be submitted to us anonymously. If you would like us to respond to your comments, then you MUST provide us with your personal information below. If you would prefer to submit this survey anonymously, then please leave this information blank.

12. Name (not required):
13. Phone number (not required):
14. Email (not required):
15. Would you like us to contact you?
Please contact me. No need to contact me unless you need more information.

Please comment on any aspect of your care that we may improve upon: