Patient/Family Satisfaction Survey - Northwest Geriatrics

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

Please rate the following:

A. Your Appointment:

1. Appointment available within a reasonable amount of time

2. Keeping you informed if your appointment time was delayed

B. Our Staff:

1. The courtesy of the person who took your call

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

3. Your phone calls answered promptly

4. Getting advice or help when needed during office hours

5. Explanation of your procedure (if applicable)

6. Your test results reported in a reasonable amount of time

7. Effectiveness of our health information materials

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

9. Your ability to contact us after hours

10. 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. Explaining things in a way you could understand

4. Instructions regarding medication/follow-up care

5. Advice given to you on ways to stay healthy

E. Your Overall Satisfaction With:

1. Our practice

2. The quality of your medical care

3. Overall rating of care from your provider or nurse

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 You:

A. Your Appointment:

B. Our Staff:

D. Your Visit with the Provider:

E. Your Overall Satisfaction With:

Some Information About Yourself: (optional)

We’d love to hear from you!