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Review Survey Template
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| | 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 wi | | 3. Your race or ethenicity | |
| 4. Easy of Gettig Care:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good, 5 = Great
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5. Waiting:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good, 5 = Great
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6. Provider: (Physician, Dentist, Physician Assistant, Nurse Practitioner)
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good | |
7. Nurses and Medical Assistants:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good | |
8. Payment:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good | |
9. Facility:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good | |
10. Confidentiality:
Please circle how well you do in the following based on the following rating scale:
1 = Poor, 2 = Fair, 3 = OK, 4 = Good | |
| 11. The likelihood of referring your friends and relatives to us: | |
| 12. Do you consider this center your regular source of care? | |
| 13. What do you like best about our center? | |
| 14. What do you like least about our Center? | |
| 15. Suggestions for improvement? | |
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