Please Rate Your Appointment
1. The length of time required between your call for an appointment and when scheduled to be seen.		Excellent	Good	Fair	Poor
2. The convenience of available appointments to your schedule.		Excellent	Good	Fair	Poor
3. The waiting time in our reception area prior to being seen.		Excellent	Good	Fair	Poor
4. The waiting time in the exam room prior to being seen by the doctor.		Excellent	Good	Fair	Poor
Comments:
Please Rate Our Facility
1. The convenience of our office hours and location.		Excellent	Good	Fair	Poor
2. The cleanliness and comfort of the office itself.		Excellent	Good	Fair	Poor
3. Our parking facilities.		Excellent	Good	Fair	Poor
4. Availability of interesting reading material for you to read.		Excellent	Good	Fair	Poor
Comments:
Please Rate Our Staff
1. The friendliness and courtesy of our receptionists.		Excellent	Good	Fair	Poor
2. The caring and courtesy of our nurses.		Excellent	Good	Fair	Poor
3. The helpfulness and courtesy of our business and insurance office personnel.		Excellent	Good	Fair	Poor
4. The friendliness and courtesy of our ultrasound and laboratory staff		Excellent	Good	Fair	Poor
Comments:
Please Rate Our Communication
1. Your ease in reaching our office by telephone.		Excellent	Good	Fair	Poor
2. Our timeliness in providing answers to your phone questions.		Excellent	Good	Fair	Poor
3. The quality of information or medical advice we provide by phone.		Excellent	Good	Fair	Poor
4. Describing tests and procedures to you prior to performing them.		Excellent	Good	Fair	Poor
5. Timely reporting of your test and procedures results.		Excellent	Good	Fair	Poor
Comments:
Please Rate Your Visit
1. The attitude and conversation between our physician and you.		Excellent	Good	Fair	Poor
2. Discussion of diagnosis and treatment options so that you understood your choices.		Excellent	Good	Fair	Poor
3. The completeness of the of the examination in light of your stated medical problem.		Excellent	Good	Fair	Poor
4. The overall satisfaction with your physician.		Excellent	Good	Fair	Poor
Comments:
Please Rate Your Overall Satisfaction
Your overall satisfaction with our practice.		Excellent	Good	Fair	Poor
Comments:
Please Complete the Following Patient Information
Would you recommend this practice to a family member or friend?				Yes	No
How many years have you been a patient in our practice?
How did you hear about us?  Family Member  Friend or Co-Worker  Another Physician Other:
Comments or Suggestions:
E-Mail Address (not required):