1. 
Appointments are scheduled in a timely fashion.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
2. 
Urgent cases are easily scheduled on short notice.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
3. 
Please share suggestions for improving appointments.

 

 
4. 
Our staff is responsive and helpful.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
5. 
Please name a staff member who was particularly helpful to you or your patients.

 

 
6. 
Consultation reports are thorough.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
7. 
Consultation reports are prompt.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
8. 
Status reports are timely and thorough.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
9. 
Communications are answered in a timely fashion.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
10. 
Which methods of communication do you prefer regarding patient treatment... email, phone, fax or mail? (So we can better serve you, please share your contact information.)

 

 
11. 
Physicians are responsive and helpful.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
12. 
Physician is competent.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
13. 
Please share how our physicians can improve for you, your staff and your patients.

 

 
14. 
Our location is convenient.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
15. 
Our facility is clean and appropriate.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
16. 
Our fees and billing practices are fair and consistent.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
17. 
Your patients are very satisfied with us.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
18. 
Your staff is very satisfied with us.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
19. 
Your physicians are very satisfied with us.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
20. 
We do a great job returning patients to your care.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
21. 
Overall quality is outstanding.

 
 Strongly Agree
 Agree
 Neither Agree nor Disagree
 Disagree
 Strongly Disagree
 N/A
 
22. 
Please share anything you'd have us change to improve your patient's experience.

 

 
23. 
Please share anything you'd have us change to improve your experience.

 

 
24. 
Please share any additional comments.

 

 
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