Satisfaction Survey

1. Was this your first visit to our office?
Yes
No

2. Reason for your visit?

3. Convenience of setting your appointment
Extremely convenient
Moderately convenient
Slightly convenient
Not at all convenient
I did not have an appointment

4. Did the receptionist introduce himself/herself and greet you in a friendly and courteous manner?
Yes
No

5. Cleanliness/neatness of the waiting room
Average
Outstanding
Poor

6. How long did you have to wait to be seen after checking in with the receptionist?
5-10 minutes
11-20 minutes
21-30 minutes
over 30 minutes
Other (please specify)
Comments:

7. How friendly was office staff?
Extremely friendly
Moderately friendly
Slightly friendly
Not at all friendly

8. Was the physician able to put you at ease?
Yes
No
Comments:

9. How well did you feel that we understood your needs?
Extremely well
Moderately well
Slightly well
Not at all well
Comments:

10. Quality of the service
Outstanding
Above Average
Average
Below Average
Poor
Comments:

11. How responsive was the staff to your questions or concerns?
Extremely responsive
Quite responsive
Moderately responsive
Slightly responsive
Not at all responsive

12. The ease of checking out and paying
Extremely convenient
Moderately convenient
Slightly convenient
Not at all convenient

13. Rate your experience with referrals to specialists (our office's ability to keep you informed and up-to-date on the status of your request)
Outstanding
Average
Poor

14.How likely is it that you would recommend Bristol Primary Care LLC to your friends or family?
Not at all likely - 0
1
2
3
4
5
6
7
8
9
Extremely likely - 10"

15. In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices and procedures.

16. Would you like to be contacted regarding this survey?
Yes
No