Patient Survey

We value your feedback. This short survey helps us understand your experience with our office so we can improve patient service and care.

Please rate the following statements based on your visit today

Name

First Last

I was greeted promptly when I arrived.

The front desk staff were friendly and courteous.

The check-in process was quick and efficient.

The front desk staff explained forms or procedures clearly.

I felt welcomed when I arrived.

Medical technicians communicated clearly and respectfully.

My questions were answered in a way I could understand.

Staff maintained a professional and calm demeanor.

I felt comfortable asking questions in the exam room.

Ease of scheduling your appointment

Courtesy and professionalism of scheduling staff

Clarity of appointment details (date, time, location)

Availability of appointment times that met your needs

Overall scheduling experience

My personal and medical information was handled privately.

Conversations at the front desk and exam rooms were conducted discreetly.

I felt respected by the staff.

I was informed about expected wait times.

Any delays were communicated clearly.

Overall, I am satisfied with my experience.

The staff contributed positively to my visit.

I would feel comfortable returning to this office.

Type of visit

New Patient

Foillow-up

Urgent

Post Operative

Questions or Comments

Receptionist Name

Physician seen by

Medical Technician

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