Q.1
Which Provider did you visit?
*
Dr. Amir
Dr. Braun
Dr. Chiravuri
Dr. Cohen
Dr. Fichera
Dr. Humayun
Dr. Katz
Dr. Ibrahim
Dr. Linzer
Dr. Marranzini
Dr. Marek
Dr. Morris
Dr. Mostoufi
Dr. Myers
Dr. Polner
Dr. Roth
Dr. Oliver Schnapp
Dr. Spiller
Dr. Splaver
Dr. Stearns
Dr. Talan
Dr. Tallet
Kip Rider, P.A.
Lisa Tallet, P.A.
Sarah A. Glantz, PA-C
Q.2
I made my appointment by:
*
Phone
Online
During my last visit
Walk-In
Through my Primary Care Physician
N/A
Q.3
When was the first available appointment when you were scheduling your appointment?
*
Less than 24 hours
1 - 2 days
3 - 4 days
5 - 6 days
7 - 8 days
9+ days
N/A
Q.4
SCHEDULING
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
It was easy to schedule my appointment.
The person who scheduled my appointment was respectful and friendly.
My phone calls were answered in a timely manner.
I was quickly directed to the person that could answer the question.
Q.5
Comments regarding your scheduling?
Q.6
REGISTRATION
*
Very Good
Good
Fair
Poor
Very Poor
N/A
Speed of the Registration Process?
Courtesy of staff in the registration area?
Comfort and pleasantness of the waiting area?
Length of wait before going to exam room
How would you rate the customer service provided at check-in/registration?
Q.7
Comments regarding your registration?
Q.8
DURING YOUR VISIT
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
The nurse/assistant was friendly and courteous.
The nurse/assistant expressed concern for your problem.
The waiting time in the exam room before being seen by a care provider was acceptable.
The answers / information / instructions provided to me by the nurse were helpful.
Q.9
Comments regarding your visit?
Q.10
Who provided your primary care?
*
Doctor
Physician Assistant (P.A.)
Nurse Practitioner (N.P.)
N/A
Q.11
YOUR CARE PROVIDER
*
Very Good
Good
Fair
Poor
Very Poor
N/A
Friendliness/Courtesy of the care provider?
Explanations the care provider gave you regarding your problem or condition?
Concern the care provider showed for your question or worries?
Care provider's efforts to include you in decisions about your treatment?
Information the care provider gave you about medications (if any)?
Instructions the care provider gave you about follow-up care?
Degree to which care provider talked with you using words you could understand?
Amount of time the care provider spent with you?
Your confidence in this care provider?
Likelihood of your recommending this care provider to others?
Q.12
Comments regarding your care provider?
Q.13
PHONE MANAGEMENT
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
If I had to leave a message, my phone call was returned in a timely manner.
It was easy to place a prescription refill over the phone.
Q.14
Comments regarding your phone experience?
Q.15
If you had to leave a message, how long did you have to wait for a return call?
*
Less than 1 hour
1 - 3 hours
4 - 8 hours
1 - 2 days
2+ days
N/A
Q.16
QUESTIONS REGARDING YOUR BILL
*
Yes
No
N/A
Was your billing statement easy to read?
If you had to contact the Billing/Collection Department, were they helpful in answering your questions?
Were the payment options listed on the statement clear?
Q.17
Comments regarding personal issues or billing
Q.18
OVERALL ASSESSMENT
*
Very Good
Good
Fair
Poor
Very Poor
N/A
Overall cheerfulness of our Practice?
Overall cleanliness of our Practice?
Overall rating of care received during your visit?
Likelihood of your recommending our Practice to others?
Convenience of our office hours?
Our sensitivity to your needs?
Our concern for your privacy?
Q.19
Comments regarding the overall practice?
Q.20
Patient's Name (optional)
Q.21
Patient's Telephone Number (optional)
Q.22
Would you like someone to contact you regarding this survey?
*
Yes
No