Patient Satisfaction Survey

We value the feedback we get from our patients. If you did not fill out the Patient Satisfaction Survey at the time of your office visit, please fill it out here. We appreciate your input.

Date of your visit

Month

Day

Year

Which clinical provider did you see on this visit?

If your appointment was with a nurse, physician assistant, or nurse practitioner, what was his or her name?

How long did you wait to check in at the desk after arriving at the office?

How long did you wait to see the doctor (or other clinical provider) after you checked in?

Were you informed of any delays?

Yes

Do you have any comments about your wait times?

About your visit (please choose the most appropriate answer on a scale of 1 through 5):

	1 Not at all	2	3 Somewhat	4	5 Very much
Did you feel you were welcomed and given personal attention?	Did you feel you were welcomed and given personal attention? - 1 Not at all	Did you feel you were welcomed and given personal attention? - 2	Did you feel you were welcomed and given personal attention? - 3 Somewhat	Did you feel you were welcomed and given personal attention? - 4	Did you feel you were welcomed and given personal attention? - 5 Very much
Did staff go out of their way to make you feel comfortable?	Did staff go out of their way to make you feel comfortable? - 1 Not at all	Did staff go out of their way to make you feel comfortable? - 2	Did staff go out of their way to make you feel comfortable? - 3 Somewhat	Did staff go out of their way to make you feel comfortable? - 4	Did staff go out of their way to make you feel comfortable? - 5 Very much
Did the waiting area meet your expectations?	Did the waiting area meet your expectations? - 1 Not at all	Did the waiting area meet your expectations? - 2	Did the waiting area meet your expectations? - 3 Somewhat	Did the waiting area meet your expectations? - 4	Did the waiting area meet your expectations? - 5 Very much
Did your doctor or other clinical provider meet your needs?	Did your doctor or other clinical provider meet your needs? - 1 Not at all	Did your doctor or other clinical provider meet your needs? - 2	Did your doctor or other clinical provider meet your needs? - 3 Somewhat	Did your doctor or other clinical provider meet your needs? - 4	Did your doctor or other clinical provider meet your needs? - 5 Very much

Do you have any comments about the office, our staff, or your doctor?

What are we doing well?

How can we improve your experience?

Please rate your overall experience on a scale of 1 to 5

Your name (optional - leave blank if you'd like to remain anonymous)

Your email address (optional - leave blank if you'd like to remain anonymous)

Your telephone number (optional - leave blank if you'd like to remain anonymous)

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Patient Satisfaction Survey

Department of Neurological Surgery