How satisfied are you with:
1. Your communication with our:
A. Front desk receptionist
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Telephone receptionist
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. Billing department staff
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
D. Nurses
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
E. Nursing Assistants
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
2. The efficiency of our:
A. Front desk receptionist
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Telephone receptionist
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. Billing department staff
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
D. Nurses
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
E. Nursing Assistants
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
3. How would you rate our nurses in terms of:
A. Responsiveness to your questions
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Time spent with patients
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. Medical knowledge
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
4. How would you rate your appointments with us:
A. Available within a reasonable amount of time
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Scheduled at a convenient time of day
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. Completed in a timely manner
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
D. Availability with provider desired
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
5. During your appointment with our PROVIDER do you feel:
A. The provider listened & your questions were answered
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. The examination was thorough
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. The amount of time spent with you was appropriate
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Who was your appointment with?
Robert Ashmore, MD
A.J. Brickler III, MD
Authur Clements, MD, PhD
David J. Dixon, DO
Alex Franz, MD
Andrea K. Friall, MD
Kenneth McAlpine, MD
Vikki M.McKinnie, MD
David O'Bryan, MD
Lori W. Rosenberg, MD
Terrie Tullos, ARNP-C
Your Comments:
6. Please rate our communication with you in the following areas:
A. Were you calls answered promptly
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Availability of medical information/advice by phone
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. The provider returning your call in a timely manner
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
D. Test results reported in a reasonable amount of time
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
E. Effectiveness of health information materials
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
7. How did you hear about us?:
Insurance Company
Internet
Newspaper
Health Fair
Radio
8. How would you rate our facility:
A. Hours of operation were convenient
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Overall comfort of office
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
C. Adequate parking
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
D. Signage and directions easy to follow
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
Your Comments:
9. Overall rating:
A. Our practice
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
B. Quality of your medical care
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Not Applicable
10. Would you recommend our office to a friend:
Yes
No
11. If available to you, would you consider an evening appointment from 5:00 pm - 8:00 pm or an early morning appointment prior to 8:00 am?:
Yes
No
12. Would you be interested in:
Yoga classes
Laser hair removal
Spider vein removal
Skin Care Products
Weight and diet control classes
Massage therapy
Patient Education Classes
Other
13. If you would like someone from our office to contact you:
Please provide your name:
, daytime phone number:
and email address:
