Patient Satisfaction Survey

Please rate your level of satisfaction.

Rating Scale
5 = Very Satisfied
4 = Satisfied
3 = Neither Satisfied nor Unsatisfied
2 = Unsatisfied
1 = Very Unsatisfied
n/a = Not Applicable

SCHEDULING

Overall, how satisfied were you with the person who scheduled your visit?*

Reason for rating? (Optional)

Overall, how satisfied were you with the person who checked you in?*

Reason for rating? (Optional)

Overall, how satisfied were you with the medical assistant or nurse who roomed you?*

Reason for rating? (Optional)

Overall, how satisfied were you with your care provider?*

Reason for rating? (Optional)

If you had an ultrasound today, how satisfied were you with your sonographer?*

Reason for rating? (Optional)

Overall, how satisfied were you with the person who checked you out?*

Reason for rating? (Optional)

Please rate the appearance of our facility.*

Reason for rating? (Optional)

Is there a department, not previous listed, you would like to leave feedback on?*

Department:

Please rate the department listed above

Reason for rating? (Optional)