Appointment Request | Send a Brochure | Pre-Visit Forms Patient Survey | Careers | Locations Our goal is to improve the quality of our patients lives. To do that, we need your help. Please let us know what we are doing right and how we can improve by filling out the following survey. All of your responses will be kept strictly confidential, so please use this opportunity to respond freely. 1. Male Female Physician/Provider who treated you: Insurance: NoneMedicareMedicaidWork.CompOther 2. Please rate your satisfaction with the following: Efficiency of telephone operator: ENTER HERE Excellent Very Good Good Fair Poor Courtesy of front office staff: ENTER HERE Excellent Very Good Good Fair Poor Availability of appointment time: ENTER HERE Excellent Very Good Good Fair Poor Prompt service at time of visit: ENTER HERE Excellent Very Good Good Fair Poor Time and interest by physician/provider: ENTER HERE Excellent Very Good Good Fair Poor Questions answered by physician/provider: ENTER HERE Excellent Very Good Good Fair Poor Illness/treatment explained by physician/provider: ENTER HERE Excellent Very Good Good Fair Poor Courtesy of nursing staff: ENTER HERE Excellent Very Good Good Fair Poor Courtesy of x-ray technologist: ENTER HERE Excellent Very Good Good Fair Poor Quality of medical care: ENTER HERE Excellent Very Good Good Fair Poor Immediate problem addressed: ENTER HERE Excellent Very Good Good Fair Poor Cost of visit: ENTER HERE Excellent Very Good Good Fair Poor 3. Overall satisfaction with your visit: ENTER HERE Excellent Very Good Good Fair Poor 4. Comments: What one thing could have made your experience a better one? Type here... Date of Service: 5. Optional: We may wish to contact you about the comments or suggestions that you've made. If you feel comfortable doing so, please leave your name and phone number. Name: Phone: