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Patient Satisfaction Survey

Appointment Information (1) Which office location did you visit? ________________________________________________________ (2) Which Provider did you see? _____________________________________________________________ (3) How were you referred to our practice?______________________________________________________ (4) Are you a new or returning patient?_________________________________________________________

Please rate your level of satisfaction for the following: 0 - N/A | | 1 - Disagree | 2 - Neutral | 3 - Agree | 4 - Strongly Agree Before Your Appointment

(5) When scheduling and appointment, the staff was courteous and helpful.

(6) I was able to make an appointment for a date and time that was reasonable and convenient to me.

Registration. (7) I was greeted and registered promptly.

(8) The registration staff was courteous and helpful.

(9) The ability to access forms on the website made the registration process more convenient and efficient.

Your Appointment (10) My healthcare provider was compassionate.

(11) My healthcare provider gave me enough time to ask questions.

(12) My healthcare provider sufficiently answered my questions.

(13) My diagnosis and treatment was adequately explained.

(14) The medical staff was professional and helpful.

(15) I know the process to ask follow-up questions after my appointment.

(16) I was able to easily schedule my next appointment.

General (17) Did we handle your payment properly?

(18) Were your phone calls returned within 24 hours?

(19) Did you visit our website before or after your appointment to learn more?

Overall Satisfaction

(20) What is your overall level of satisfaction with our practice?

1 Yes

3 No

(21) Would you recommend CFSOM to a friend or family member?

(22) We welcome additional comments or recommendations on ways to improve our service: