Patient Satisfaction Survey

1) Did you have an appointment?

 Yes No

Please tell us how satisfied or dissatisfied you were with each of the following:

2) How satisfied were you with the way you were treated by the staff at our office?

 Very Satisfied Somewhat Satisfied Very Dissatisfied

3) How satisfied were you with the way you were treated by the doctor’s assistants?

 Very Satisfied Somewhat Satisfied Very Dissatisfied

4) The doctor?

 Very Satisfied Somewhat Satisfied Very Dissatisfied

5) The amount of time the doctor spent with you?

 Very Satisfied Somewhat Satisfied Very Dissatisfied

6) Overall, would you say your visit to our office was very positive, somewhat positive, somewhat negative or very negative?

 Very Positive Somewhat Positive Somewhat Negative Very Negative

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