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Patient Satisfaction Survey

Page One

1. Scheduling

Space Cell	5	4	3	2	1
Telephone answered promptly
Knowledge of person answering call
Appointment scheduling process
Appointment time was convenient

2. Facility

Space Cell	5	4	3	2	1
Parking
Building appearance
Cleanliness of public spaces
Cleanliness of exam rooms

3. Registration

Space Cell	5	4	3	2	1
Receptionist greeting
Check-in process
Check-out process

4. Visit

Space Cell	5	4	3	2	1
I was seen on time
I waited a reasonable amount of time

5. Approximately how long was your wait?


Taken Early	No Wait	1-15 mins	16-30 mins	31+ mins

6. Staff

Space Cell	5	4	3	2	1
Nurse / Clinical Staff
X-ray Staff

7. Physician I saw:

Dr.

8. Overall comments - How can we improve?

9. How did you select our practice?

10. Name of family doctor:

Dr.

11. Would you recommend us to others?

12. Your name (optional):

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