Patient Satisfaction Survey.

Dear Patient and Family:

We appreciate your confidence in us. Your satisfaction is important to us. We would like you to tell us how we’re doing. You can download the questionnaire here (66KB) and either mail it to us at 1 Children’s Plaza, Dayton, OH 45404 or bring to your next appointment. Alternatively, you can complete the questionnaire below, online.

Thank you in advance for completing this questionnaire.

1. What was the purpose of your visit to our office? (select one)
Initial evaluation
Follow-up exam
Second opinion
Emergency
Other:

2. Patient ’s Doctor:

3. Patient is: Male Female

4. Patient’s Age:

5. (If Applicable) Parent or Guardian’s Age:

6. Your ZIP Code:

7. Was this your first appointment with this practice?
Yes No

8. How did you hear about our practice?

9. How long did it take to get this appointment with us?

10. After processing your paperwork, how long did you wait before being seen by the doctor?

11. I would prefer to see the doctor:

12. Please tell us how strongly you agree or disagree with the following statements. Please check one. Skip any that do not apply.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
ABOUT OUR SERVICE
a. I got an appointment when needed.
b. If needed, emergency services were provided satisfactory.
c. Our nurse was helpful/courteous on phone.
d. Our assistant was helpful/courteous on phone.
e. Our office receptionist was helpful/courteous on phone.
f. Our nurses were professional/caring.
g. Our cast technicians were friendly/ courteous.
h. Our business office staff was friendly/courteous.
ABOUT YOUR BILLS AND INSURANCE
i. Staff was helpful in processing insurance claims.
j. Office has sent me accurate bills.
ABOUT OUR DOCTOR
k. The doctor treated us with respect.
l. The doctor answered my questions.
m. The doctor provided easy-to-understand follow-up instructions and explanation of treatment.
n. The doctor spent enough time examining the patient.
o. The doctor's appearance was professional.
p. The doctor provided an overall high quality of care.
q. I would recommend this doctor to friends.
OTHERS
r. Appearance of the office staff was professional.
s. The office was neat and pleasant.
t. Parking was adequate.
u. Adequate explanation for extended wait was given.

13. Additional Comments / Can you suggest any service improvements?

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