Patient Survey Form
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Patient Name
Answer
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Doctor Name
Answer
E-mail AddressÂ
Answer
Gender
Choose one of the following answers
Male
Female
*
How would you rate your overall visit?
Choose one of the following answers
Poor
Fair
Average
Good
Excellent
How did you find the appointment Scheduling process?
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Poor
Fair
Average
Good
Excellent
How would you rate our Receptionist / Staff ?
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Poor
Fair
Average
Good
Excellent
How would you rate the cleanliness of our office?
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Poor
Fair
Average
Good
Excellent
How would you rate your wait time ?
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Poor
Fair
Average
Good
Excellent
Were you seen by the doctor in a reasonable amount of time?
Choose one of the following answers
Over 45 Minutes
45 Minutes Late
30 Minutes Late
15 Minutes Late
On time
Were your financial options explained to you?
Choose one of the following answers
Yes
No
Did you understand the cost before the treatment was started?
Choose one of the following answers
Yes
No
How was the quality of care?
Choose one of the following answers
Poor
Fair
Average
Good
Excellent
Did your doctor manage your discomfort?
Choose one of the following answers
Yes
No
I am still in a lot of pain
Did you have a good understanding of your health situation after your appointment?
Choose one of the following answers
Yes
No
Would you recommend us to your friends and family?
Choose one of the following answers
Yes
No
Please comment on how we can make your visit better.
Answer
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