Facility Satisfaction Survey - Northwest Geriatrics

Dear Patient: Dear Provider: Please tell us your opinion about the service you received from your prescriber. Your responses will be kept strictly confidential. Thanks for your help.

Please rate the following:

A. Your Access:

1. Assistance available within a reasonable amount of time

2. Getting help for illness/injury as soon as you wanted it

3. Getting after-hours help when you needed it

4. Keeping you informed if your visit time was delayed

B. Office Staff:

1. The courtesy of the person who took your call

2. The helpfulness of the people who assisted you with billing or insurance

C. Our Communication With You:

1. Your phone calls answered promptly

2. Getting advice or help when needed during office hours

3. Lab/test results reported in a reasonable amount of time

4. Effectiveness of our health information materials

5. Our ability to return your calls in a timely manner

6. Your ability to contact us after hours

7. Your ability to obtain prescription refills

D. Your Visit with the Provider:

(Doctor, Physician Assistant, Nurse Practitioner)

1. Willingness to listen carefully to you

2. Taking time to answer your questions

3. Instructions regarding medication/follow-up care

E. Your Overall Satisfaction With:

1. Our practice

2. The quality of your medical care

Would You Recommend the Provider to Others?

If no, please tell us why:

Would you like a manager to call you?

If there is any way we can improve our services to you, please tell us about it:

Some Information About Yourself: (optional)

Your Name:

First Last

Phone Number:

Your Email:

Gender:

Your Age:

Are We: