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Patient Satisfaction Survey
WE APPRECIATE IT IF YOU CAN ANSWER OUR SHORT SURVEY.
Date of Visit
*
First Name
*
Last Name (Initial Only)
*
1.
I was able to make an appointment that was convenient for me:
Strongly Agree
Agree
Disagree
Strongly Disagree
2.
Administrative staff treated me with courtesy and respect:
Strongly Agree
Agree
Disagree
Strongly Disagree
3.
My Doctor given me information in a way I understood:
Strongly Agree
Agree
Disagree
Strongly Disagree
4.
My Doctor treated me with courtesy and respect:
Strongly Agree
Agree
Disagree
Strongly Disagree
5.
Overall, I was satisfied with my experience during my visit:
Strongly Agree
Agree
Disagree
Strongly Disagree
6.
I would highly recommend this doctor to my family and friends:
Strongly Agree
Agree
Disagree
Strongly Disagree
Please provide us with any comments below:
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