Patient Satisfaction - Sample

1. Helpfulness of the front desk staff. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

2. If you interacted with our scheduling staff, how would you rate their helpfulness and their effort to accommodate you. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

3. Wait time at [Practice Name] (from arrival to departure, please keep in mind your appointment time). *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

4. Courtesy of the person who conducted your exam or procedure. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

5. Staff's explanation of what would happen during exam or procedure. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

6. If you saw a doctor during your visit, how would you rate them regarding their friendliness, courtesy and professionalism? *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

7. Cleanliness of [Practice Name]. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

8. Concern shown for your privacy. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

9. Overall satisfaction with your visit. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

10. Likelihood to recommend [Practice Name] to your friends and family. *

1. Very poor 2. Poor 3. Fair 4. Good 5. Very Good

11. Would you like to recognize any employees within [Practice Name]?

12. Please feel free to comment regarding your service:

13. Name: (Optional)

14. Would you like to be contacted regarding your visit? *

Yes No

15. If you answered Yes to the question above please enter the phone number you would like to be contacted at below: