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    Healthwise Family Care Network
Patient Satisfaction Survey
 
We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.
 
       
     
Age:
Sex:     
Date of Visit:
Provider Seen:
       
     
Ease of Getting Care GREAT GOOD OK FAIR POOR
  5 4 3 2 1
           
Ability to get in to be seen
Hours office is open
Convenience of office location
Prompt return on calls
       
     
Waiting
           
Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for test results
       
     
Staff: Provider (Physician, Physician Assistant, Nurse Practicioner)
           
Listens to you
Takes enough time with you
Explains what you want to know
Gives good advice & treatment
       
     
Staff: Nurses & Medical Assistants
           
Friendly & helpful to you
Answers your questions
       
     
Staff: All Others
           
Friendly & helpful to you
Answers your questions
       
     
Payment
           
What you pay
Explanation of charges
Collection of payment/money
       
     
Facility
           
Neat and clean building
Ease of finding where to go
Comfort & Safety while waiting
Privacy
       
     
Confidentiality
           
Keeping my information private
       
     
Would you recommend us?
           
Likelihood of referring your friends and relatives to us
       
      Do you consider this center your regular source of care?     
       
      What do you like best about our office?
       
      What do you like least about our office?
       
      Suggestions for Improvement