Check The Office You Are Providing Feedback On:

Check One: 1=Strongly Agree or 4=Strongly Disagree

1

2

3

4

1. Do we answer the phone promptly and politely?

2. Are you kept on "hold" too long?

3. Are all of your questions answered satisfactorily?

4. Do we return your calls promptly?

5. Do we see you on time?

6. Is our reception area clean and comfortable?

7. Do we give you complete information regarding insurance coverage?

8. In an emergency, is it easy for you to get in touch with our office?

9. Are you greeted pleasantly upon arrival?

10. Does our staff seem genuinely interested in you?

11. Are you treated with compassion and respect?

12. Are the doctor and staff attentive to your needs and concerns?

13. Does our staff spend adequate time with you?

What do you like best about our office?

Comments:

What do you like least about our office?

Comments:

Testimonial (Please include your name if you would like).

Comments:

 

Are you referring your friends and colleagues to our office?

Yes

No

Are you pleased with the results you are seeing?

Yes

No

Are our parking facilities adequate?

Yes

No

Is our office easy to find?

Yes

No

Can we use your testimonial in print and/or on the website?

Yes

No