Referral Survey - Vital Check

1. Patients can schedule an appointment with Dr. Smith within 72 hours. *

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

2. I can easily reach Dr. Smith on the telephone when I need to discuss a patient. *

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

3. My patients seem to have a good overall experience with Dr. Smith. *

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

4. I receive Dr. Smith's consultation report in a timely manner. *

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

5. Is there anything else we could do to make referring patients to our office easy and effective?

6. How do you prefer to be contacted about your patients? (Choose one): *

Telephone Fax Email Cell Phone Pager Regular Mail

7. Would you appreciate periodic journal articles or emails about the latest treatments and procedures? *

Yes No

8. My email address:

9. Name: