Patient Survey Form
New Patient
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No
Returning Patient
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No
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Patient Name
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Gender
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Male
Female
Age - Years
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<30
31-41
41-50
>51
E-mail AddressÂ
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*
Doctor Name
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Phone No
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How did you find the appointment Scheduling process?
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Average
Good
Excellent
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The ethics of the person (s) who scheduled your appointment
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Average
Good
Excellent
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Your test results reported in a reasonable amount of time
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Average
Good
Excellent
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The service/care provided was valuable to improve your health?
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Average
Good
Excellent
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Did the physician review the information about your medical history?
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Average
Good
Excellent
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Was our staff competent in performing their tasks?
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Average
Good
Excellent
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Did the physician listen carefully to you and spent enough time with you?
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Average
Good
Excellent
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Were your financial options explained to you?
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Average
Good
Excellent
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Would you recommend us to your friends and family?
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Average
Good
Excellent
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Any other suggestion/comments?
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