Note: Items marked with " * " are optional.

* First Name:
* Last Name:
* Telephone:
* E-Mail:

1. Did you have any difficulties getting an appointment?	Yes     No
2. Did the receptionist introduce him/herself on the phone?	Yes     No
3. Was the receptionist friendly (pleasant) on the phone?	Yes     No
4. Was your wait in the waiting room long?	Yes     No
5. If yes, were the reasons for your wait explained to you?	Yes     No
6. If this is your first visit, did staff members identify themselves by name and job title?	Yes     No
7. Were the staff members courteous and professional?	Yes     No
8. Did the physician discuss your problem?	Yes     No
9. Did you understand the explanation?	Yes     No
10. Were treatments or instructions fully explained to you?	Yes     No
11. Did you understand those explanations?	Yes     No
12. Were you given enough privacy?	Yes     No
13. Were our billing policies explained to you clearly?	Yes     No
14. Would you recommend our practice to a friend or a relative?	Yes     No
Please complete the following statements: I chose to come to you today because….. One improvement I’d like to see is….. I wish you would…. I wish you or your staff would… Is there anything else you’d like to say?