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Patient Satisfaction Survey

We need your help to improve our services.

Your feedback offers valuable insight regarding the care and comfort of our patients. And based on the results of past surveys, we have implemented many changes in our practice.

Thank you in advance for taking the time to complete this confidential questionnaire about the care you received today. All comments will remain confidential.

Your Visit

1.	Which Provider did you see? *	Select a provider Christopher Brown, M.D. Ralph Garretson, M.D. Jeffery Wise, M.D. Charles Seal, M.D. James Ramser, M.D. Robert Smith, M.D. David Kim, M.D. Daniel Heller, M.D. Michelle Glowicki, P.A. Kelley Schimier, P.A. Chris Hydock, P.A. Elizabeth Gabrielle, P.A. Andy Dart, P.T. Jennifer Wilkins, P.T. Ellen Meekins, O.T. Karri Voskuhl, P.T. Julie Royal, P.T.
2.	What service did you receive on your last visit?	Select a service Orthopaedic Care Pain Medicine Physicial Therapy Treatment Surgical Procedure Other
		Other:

Before Your Appointment

3.	When scheduling my appointment, the phone staff was courteous and helpful.	1	2	3	4	5
4.	I was able to schedule an appointment at the time I needed.	1	2	3	4	5
5.	The instructions I received prior to my visit were clear and helpful.	1	2	3	4	5

During Your Appointment

6.	I was greeted and registered promptly.	1	2	3	4	5
7.	The registration staff was courteous and helpful.	1	2	3	4	5
8.	The forms I was asked to complete were easy to understand.	1	2	3	4	5
9.	I was in the outer waiting room for a reasonable about of time.	1	2	3	4	5
10.	I waited in the examination room for a reasonable amount of time.	1	2	3	4	5
11.	My healthcare provider was compassionate.	1	2	3	4	5
12.	My healthcare provider gave me enough time to ask questions.	1	2	3	4	5
13.	My healthcare provider sufficiently answered my questions.	1	2	3	4	5
14.	My diagnosis and treatment was adequately explained.	1	2	3	4	5
15.	I understand the treatment plan and next steps.	1	2	3	4	5
16.	The nursing staff was professional and helpful.	1	2	3	4	5
17.	I know the process to ask follow-up questions after my appointment.	1	2	3	4	5
18.	I was able to easily set-up my next appointment.	1	2	3	4	5

General

19.	Did we obtain any authorizations or pre-certifications necessary?	Yes No N/A
20.	Did we handle your payment properly?	Yes No N/A
21.	Are your billing statements easy to understand?	Yes No N/A
22.	Were your phone calls returned within 24 hours?	Yes No N/A
23.	Did you visit our website before or after your appointment to learn more?	Yes No N/A
24.	Will you recommend us to others?	Yes No N/A
25.	What did you like best about our office staff, doctor or nurse? Is there someone you'd like to thank for being especially helpful or caring?
26.	How can anyone you interacted with improve? Is there a staff member that needs to address any issues that were not dealt with to your satisfaction? (All survey information will be confidential and no names will be released to the staff or providers.)
27.	Would you like to be contacted to discuss any concerns?	Yes No
	If yes, please provide us information to contact you: Name: Phone: Email: What is your preferred method of contact? Phone Email Would you like to receive further information about: Orthopaedic Services Pain Medications or Treatment Physical Therapy Services

 

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