Dear Patient,

In our efforts to continually serve you as best as possible we would like you to take a few moments to fill out this quick survey. This survey should take less than 5 minutes to complete.

General (please circle your responses)
1. Are you happy with the services you receive at the office? YesNo
I. Are your phone requests answered when you call the office? YesNo
2. Is the staff friendly over the phone? YesNo
3. Are you able to schedule appointments when you request them? YesNo
4. Is the office professional over the phone? YesNo
5. Is the office professional in person? YesNo
Physician Services
I. Are you happy with the services provided by the doctor? YesNo
2. Are you seen within 15 minutes after being placed in the exam room? YesNo
3. Are your questions answered by the doctor during your visit? YesNo
4. Do you consider yourself healthy? YesNo
5. Do you refer people to the office for medical services? YesNo
6. Will you continue to refer people to the office if you already do? YesNo
Physician Services

Thank you for your time.