Jump to Content.
Jump to Navigation.
Jump to Sidebar.
Jump to Footer.

Patient Satisfaction Survey
Please take a few minutes of your time to help us. Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We would like to know how you feel about our patient handling systems, our providers and our staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs. All responses to this survey are anonymous. Thank you for your help.
Strongly
Agree		 Agree Disagree Strongly
Disagree		 Not
Applicable
1. In regards to this survey, which office are you reporting on? *
2. Please enter the date of the visit you are reporting. (mm/dd/yyyy) *
3. I was able to schedule my appointment for this visit within a reasonable amount of time. *
4. When I called the office during regular office hours, I received the help or advice I needed. *
5. If I had to leave a message, I received a call back that same day. Yes    No    Not Applicable *
If "No", what was the unreturned call regarding?
6. The front office staff met and greeted me promptly and courteously. *
7. The nursing staff greeted me promptly and courteously. *
8. The nurses spent an appropriate amount of time with me to understand and communicate my medical needs. *
9. How many minutes did you have to wait to see the provider? 5 15 30 45 45+ *
10. The provider listened to me and my problems and showed respect and concern for what I had to say. *
11. The provider explained things in a way I could understand. *
12. The provider spent enough time with me at this visit to discuss the problem I came in for. *
13. Which provider did you see? *
14. When I checked out, the staff member collected my payment, or explained the insurance billing if needed. *
15. If I received a referral to a specialist at my visit, it was handled in a timely manner and to my satisfaction. *
16. I would recommend your facility to others. *
17. I was satisfied with the service from FPCA staff and my provider and the overall quality of my visit. *
18. I am insured by:
*
19. I am satisfied with the level of service provided by my insurance plan. *
20. I am: Male    Female *
21. My age is: Under 18   19-30   31-40   41-50   51-60   Over 60
*
22. My comments or suggestions for improvement of my visit are:
* - denotes required fields