Patient survey form

When you phoned this office to get an appointment, how often did you get an appointment as soon as you thought you needed?
 Never Sometimes Usually Always

Were we courteous and friendly?

 Yes, definitely Yes, somewhat No

How often did you see the practitioner within 15 minutes of your appointment time? Wait time includes spent in the waiting room and exam room.

 Never Sometimes Usually Always

Did the practitioner explain things in a way that was easy to understand?

 Yes, definitely Yes, somewhat No

Did the practitioner listen carefully to you?

 Yes, definitely Yes, somewhat No

Did the practitioner show respect for what you had to say?

 Yes, definitely Yes, Somewhat No

Were you satisfied with our products and services?

 Yes, definitely Yes, Somewhat No

If no, Please explain

Would you be willing to recommend us to friends or relatives?

 Yes, definitely Yes, somewhat No

Rating of the practitioner

Using any number from 0 to 5, where 0 is the worst practitioner and 5 is the best possible, what number would you used to rate the practitioner?

 0 Worst doctor possible 1 2 3 4 5 Best Possible

Any additional comments

Patient name (optional)