Patient Satisfaction Survey
Dear Patient:
Our Practice wants to provide you and all of our patients the best possible care.
To help us become aware of aspects of the practice that might be improved, won’t you please take a minute to answer the following questions?
Your comments will remain anonymous, although a space is provided for your name if you wish to identify yourself.
Thank you for taking the time to complete our survey.
— Kansas City Bone and Joint Clinic, P.A. |
| 1. How did you hear about us? |
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| 2. Age: |
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| 3. Sex: |
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| 4. Insurance (Blue Cross & Blue Shield, Aetna, CIGNA, Workcomp, etc.) |
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| 5. Which provider did you see? |
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| Based on your experience, please rate the following questions. |
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Extremely Satisfied |
Very Satisfied |
Satisfied |
Somewhat Dissatisfied |
Very Dissatisfied |
Not applicable |
| 6. Are you satisfied with the time required to get an appointment? |
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| 7. If you telephoned our office were you satisfied with how we handled your call? |
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| 8. Were you advised of any information (x-ray, referral form, etc.) or need for early arrival? |
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| 9. Were office policies regarding payment and insurance requirements communicated to you in a clear and courteous manner? |
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| 10. Were you greeted with friendliness and prompt assistance at reception? |
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| 11. If you called our office after hours or on a holiday, did the answering service answer the telephone promptly and courteously? |
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| 12. If you requested a call back, did you recieve it promptly? |
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| 13. Satisfaction with length of time spent waiting at office to see the provider? |
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| 14. Was the office staff friendly, Courteous, helpful & professional? |
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| 15. Satisfaction with explanation of treatment or test by provider or staff? |
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| 16. Satisfaction with attention by Provider to what you had to say? |
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| 17. Satisfaction with the personal manner (courtesy, respect, sensitivity, friendliness) of the provider? |
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| 18. Satisfaction with the amount of time provider spent with you? |
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| 19. What is the likelihood that you would recommend this provider to family and friends? |
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| 20. Satisfaction with the visit overall? |
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| 21. Did you have an excessive wait for any of our services, if so, which service? |
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| 22. How might the service of our practice be improved? |
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| 23. Your comments on parking, grounds, buildings, location, etc. |
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| 24. Additional comments: |
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| The following questions are optional |
| 25. Phone Number: (Daytime) |
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| 26. Phone Number: (Evening) |
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| 27. Would you like someone to respond to your concerns? |
Yes |
No |
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| 28. Name: |
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| 29. Email Address: |
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| 30. Time when convenient to call: |
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