Fields marked with an * are required Instructions Please take a few minutes to fill out this survey on the timeliness and quality of the service you received today. We welcome your feedback and your answers will be kept confidential. Thank you for your participation. * Very Courteous Courteous Pleasant Rude Very Rude When scheduling your appointment was the receptionist who scheduled your appointment courteous and helpful? * Very Courteous Courteous Pleasant Rude Very Rude On the day of your appointment, how would you rate the courtesy of our staff? * 0 - 5 min. 5 - 10 min. 10 - 20 min. 20 - 40 min. 40 - 60 min. more than 60 min How long did you wait in the reception area beyond your scheduled appointment time? * Yes No Did you feel that your doctor spent an adequate amount of time with you? * Yes No Did you feel that your doctor was empathetic and responsive to your concerns? * Yes No Did you feel that your doctor showed a willingness to listen and answer your questions? Please list any areas in which our service could be improved, or share additional comments. Name (Optional) Email (Optional) If you are a human seeing this field, please leave it empty.
