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Exit Survey
 
How satisfied are you in regards to your appointment?
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied N/A
Ease of making appointments by phone
Appointment available within a reasonable amount of time
The effieciency of the check-in process
Waiting time in reception area
Waiting time in exam room
Kepping you informed if your appointment time was delayed
Ease of getting a referral when you needed one
 
 
How satisfied are you with the following in regards to our staff?
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied N/A
The courtesy of the person who took the call to schedule appointment
The friendliness and courtesy of the receptionist
The caring concern of our nurses/medical assistants
The helpfulness of the people who assisted you with billing or insurance
Overall professionalism of staff
 
 
How satisfied are you with our communication with you?
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied N/A
Your phone calls answered promptly
Getting advice or help when needed during office hours
Explanation of your procedcure
Your test results reported in a reasonable amount of time
Effectiveness of our health information materials
Our ability to return your calls in a timely manner
Your ability to contact us after hours
 
 
How satisfied are you with your visit with the provider?
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied N/A
Willingness to listen carefully to you
Taking time to answer your questions
Amount of time spent with you
Explaining things in a way you could understand
Instructions regarding medication/follow up care
The thoroughness of the examination
Advice given to you on the ways to stay healthy
 
 
Please rate our facility:
Hours of operation convenient for you
Overall comfort
Cleaniness of waiting room
Cleaniness of exam rooms
Adequate parking
Signage and directions easy to follow
Convenience of location for you
 
 
 
Where your financial options explained?
 
yes
 
no
 
I already understand my financial options
 
 
 
Did our team provide information regarding parking and directions while on the phone?
 
yes
 
no
 
 
 
Would you refer your friend or family to us?
 
yes
 
no
 
 
 
What kind of medical insurance coverage do you have?
 
None
 
Private/Commercial
 
Medicaid
 
Medicare
 
Not sure
 
Other
 
 
 
 
Do you have any additional comments/suggestions:
   
Name and Date of visit (Please write anonymous if you do not want to disclose your name):