Patient Satisfaction Survey
We are in the process of developing a health education program for our patients as well as looking for ways
to improve and efficiently provide care to our patients. I appreciate you taking the time to share your
thoughts with us.
1. What was your INITIAL IMPRESSION upon entering the office on a scale of 1 (poor) to 5
(outstanding) ? Rating: 1 2 3 4 5
2. In choosing our office for health care, what primarily influenced your decision to come to us:
• Referral from another doctor
• Referral from another family member or friend
• Referral from a satisfied patient
• Yellow pages
• Providence hospital referral line
• Alaska Regional hospital referral line
• Other ________________________________
3. Do our reminder letters and phone calls help you remember your check up times?
4. Did the doctors and the staff treat you with dignity and respect?
5. Do you feel comfortable and “welcome” whenever you visit the office?
6. Was the office staff FRIENDLY, COURTEOUS, and HELPFUL? Yes No
7. Are you able to get APPOINTMENTS in a timely fashion? Yes No
8. Are you able to easily access the nurse for related questions? Yes No
9. Are you able to access the physician when you need to? Yes No
10. Are you satisfied with laboratory service we provide IN HOUSE? Yes No
11. We do Courtesy INSURANCE BILLING for our patients at no charge. Are you satisfied with this
service? Yes No
12. Are you billing questions handled efficiently by the office staff? Yes No
13. Are you satisfied with our ANSWERING SERVICE to reach the on call doctor after hours and
weekends? Yes No
14. Are you health concerns/ issues and question handled by the physician and the staff in a courteous
and professional manner? Yes No
15. If required, were our payment procedure options flexible to meet your needs? Yes No
16. How would you rate YOUR OVERALL SATISFACTION at this office on a scale of 1 (poor) to 5
(excellent) ? 1 2 3 4 5
17. What positive changes or additions can we make to benefit you as a patient?
18. Any other comments that you with to make (e.g. what you really liked or dislike about our office.)
OPTIONAL: Patients Name __________________________________________
ALL RESPONSES WILL BE KEPT STRICTLY CONFIDENTIAL. THANK YOU.