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PATIENT SATISFACTION SURVEY

We are interested in receiving your feedback about the care and service you received at IIMC. Your responses are important to us, and will help us evaluate how to provide the best level of service possible. Thank you for taking a few minutes to complete this survey.

DEMOGRAPHICS

Clinic visit date:

Was this your first visit to our clinic?  Yes    No

Physician seen:

Patient Gender: F    M

Patient name (optional):    Age:

Relationship to Patient:

SURVEY

Any comments which would provide clarity regarding your answers are appreciated. Please circle the appropriate response.

How satisfied are you with:

ACCESS TO CARE?

N/A

Extremely
Dissatisfied

Very
Dissatisfied

Satisfied

Very
Satisfied

Extremely
Satisfied

Ease of scheduling appointment

Courtesy of scheduler

Promptness returning calls

Ease of getting through on phone

Comments:

ASPECTS OF YOUR VISIT?

N/A

Extremely
Dissatisfied

Very
Dissatisfied

Satisfied

Very
Satisfied

Extremely
Satisfied

Courtesy of front desk staff

Comfort in waiting area

Length of wait before being seen

Friendliness/concern of nurse

Comments:

YOUR PHYSICIAN?

N/A

Extremely
Dissatisfied

Very
Dissatisfied

Satisfied

Very
Satisfied

Extremely
Satisfied

Friendliness/courtesy of physician

Explanation physician gave you
about your problem/condition

Physician's efforts to include you
in decisions about your treatment

Follow up instructions about
medications or care

Degree to which physician
answered questions/concerns

Amount of time the physician
spent with you

Your confidence in physician

Will you recommend this physician
to others?    YES     NO

Comments:

BILLING

N/A

Extremely
Dissatisfied

Very
Dissatisfied

Satisfied

Very
Satisfied

Extremely
Satisfied

Accuracy of billing statements

Promptness in answering
questions about your bill

Comments:

OVERALL VISIT

N/A

Extremely
Dissatisfied

Very
Dissatisfied

Satisfied

Very
Satisfied

Extremely
Satisfied

Cheerfulness of staff

Cleanliness of our facility

Overall rating of care received

Will you recommend our practice
to others?       YES    NO

Comments:

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