Annual Patient Satisfaction Survey

ANNUAL PATIENT SATISFACTION SURVEY

At ______, we strive to deliver the highest quality foot care to you and your family. Please help us identify our areas of strengths and weaknesses so that we may continue to serve you better. Your answers are strictly confidential. Please answer only those questions that apply to you. If additional space is required for your comments, please use the reverse side. You may either place the completed survey in the carton located in the reception area, or mail it back to us in the provided stamped envelope. Thank you for your time and valuable insight.

Please Rate Your Appointment

1. The length of time required between your call for an Excellen Good Fair Poor appointment and when scheduled to be seen. t

2. The convenience of available appointments to your Excellen Good Fair Poor schedule. t

3. The waiting time in our reception area prior to being Excellen Good Fair Poor seen. t

4. The waiting time in the exam room prior to being Excellen Good Fair Poor seen by the doctor. t Other comments:

Please Rate Our Facility

Excellen 1. The convenience of our office hours and location. Good Fair Poor t

Excellen 2. The cleanliness and comfort of the office itself. Good Fair Poor t

Excellen 3. Our parking facilities. Good Fair Poor t

4. Availability of interesting reading material for you to Excellen Good Fair Poor read. t Other comments:

Please Rate Our Staff

Excellen 1. The friendliness and courtesy of our receptionists. Good Fair Poor t

Excellen 2. The caring and courtesy of our assistants Good Fair Poor t

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3. The helpfulness and courtesy of our business and Excellen Good Fair Poor insurance office personnel. t

4. The helpfulness and courtesy of any facility that we Excellen Good Fair Poor referred you to (hospital, lab, MRI, etc.) t Other comments:

Please Rate Our Communication

Excellen 1. Your ease in reaching our office by telephone. Good Fair Poor t

2. Our timeliness in providing answers to your phone Excellen Good Fair Poor questions. t

Excellen 3. The quality of information that we provide by phone. Good Fair Poor t

4. Describing tests and procedures to you prior to Excellen Good Fair Poor performing them. t

Excellen 5. Timely reporting of your test and procedures results. Good Fair Poor t Other comments:

Please Rate Your Visit

1. The attitude and conversation between our Excellen Good Fair Poor physician and you. t

2. Discussion of diagnosis and treatment options so Excellen Good Fair Poor that you understood your choices. t

3. The completeness of the examination in light of your Excellen Good Fair Poor stated medical problem. t

Excellen 4. The overall satisfaction with your physician. Good Fair Poor t Other comments:

of 3 SOS Healthcare Management Solutions, LLC www.soshms.com Please Rate Your Overall Satisfaction

Excellen Your overall satisfaction with our practice. Good Fair Poor t

You are our best judge. Please tell us how we can improve to better meet your needs:

Would you recommend this practice to a family member or friend? Yes No

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