Satisfaction Survey

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National Patient Satisfaction Survey
Last name of the doctor you saw today:
Code for survey:
Why did you choose This doctor?	Telephone directory Friend/Family IPA Other doctor referred Insurance Book Other
Question	Strongly Agree	Agree		Disagree	Strongly Disagree		No Opinion
My doctor was courteous
My doctor understood my problem or condition
The explanations my doctor gave me were helpful
All other staff members were courteous
I was satisfied with the treatment provided
The facility scheduled appointments at convenient times
My visit was scheduled quickly
It was easy to schedule future appointments
I was seen promptly when I arrived for treatment
The location of the facility was convenient for me
Parking was available for me
My bills were accurate
The cost of treatments I received were reasonable
I was satisfied with the overall quality of my care
I would recommend this facility to family or friends
I would return to this facility for care in the future
My privacy was respected during my care
Overall, I was satisfied with my experience here
Your age:
Your gender:	Male	Female
Your ethnicity:	Caucasian/White		Hispanic/Latino			Black/African
	Asian/Pacific Islander		Other
Was this your first visit with this doctor?	Yes	No
Was this your first experience with this type of care?	Yes	No
Choose the BEST description of your problem:	Urgent	Chronic		Minor	Other
What did you like BEST about your experience:
What did you like LEAST about your experience:


IMPORTANT: This section is required. It will be used for verification purposes ONLY.
First Name: Last Name:
Date of Visit:
Street Address:
City:
State:
Zip:
Telephone:
Email:
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