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How Are We Doing?

Please complete this survey so we may improve the quality of care for our patients. However, please do not sign this fill this out unless you have previously signed a HIPAA release with us and reviewed our Notice of Privacy Practice. Thank you!

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Please provide the following information to help us best serve you.

First Name
Last Name
Email
Phone
1.
Month of Visit:
2.
This is my first visit:
           
3.
I was referred to the practice by:
           

If Other, please specify:
Instruction Please rate the following items:
4.
Ease of making my appointment:
              
5.
Appointment available within a reasonable amount of time:
              
6.
Ease of check-in and registration process:
              
7.
Waiting time in the reception area:
              
8.
Waiting time in the exam room:
              
9.
Ease of getting a referral:
              
10.
The courtesy and respect of the people I spoke with on the phone:
              
11.
The courtesy and respect of the nursing staff:
              
12.
The courtesy and respect of the care providers (physicians, nurses):
              
13.
The courtesy and respect of the sonographers:
              
14.
The courtesy and respect of the genetic counselor:
              
15.
The helpfulness of the people in the business office:
              
16.
My phone calls were answered promptly:
              
17.
Availability of medical information/advice by telephone:
              
18.
Ability to obtain prescriptions by phone:
              
19.
Test results reported in a reasonable amount of time:
              
20.
Explanations concerning procedures and tests during my pregnancy:
              
21.
Ability to contact the office after hours:
              
22.
Care provider listened to my questions and concerns:
              
23.
Care provider answered my questions:
              
24.
Care provider’s instructions relate to my care or treatment:
              
25.
Hours of operation:
              
26.
Overall comfort of the office/facility:
              
27.
Availability of parking:
              
28.
Office/facility signs and directions are easy to follow.
              
29.
Overall satisfaction with the practice:
              
30.
Overall satisfaction with the quality of my medical care:
              
31.
I would recommend the practice to others.
           
32.
If no, please explain why.
33.
My office visit included:
        
34.
The provider who cared for me during my visit was:
35.
My age group is:
              
36.
Please use the space provided below for any additional comments.
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