PatientSurvey

Patient Survey

It is our goal to give you the best possible medical care. To do that, it is important that we know your
thoughts about the care you are receiving. We need to know what we are doing right and in what areas we
need to improve. Your comments will be kept strictly confidential. Thank you for your help.

Before appointment:

1. Is this your:

2. Why did you decide to seek medical treatment at this office?

3. When you called our office for your initial appointment,
how long were you told it would take to be scheduled?

days

4. When you called:

5. The person who answered
your call was:

(1= unpleasant 5 = courteous)

After appointment:

1. How were you treated when you
arrived for your appointment?

(1= unpleasantly 5 = courteously)

2. Which doctor did you see?

3. After you arrived, how long did you have to wait and see the doctor?

minutes

4. The doctor's assistant(s) seemed:

(1= unpleasant 5 = courteous)

5. How were you treated by the
office staff during your visit?

(1= unpleasantly 5 = courteously)

6. Were you satisfied with the amount
of time the doctor spent with you?

(1= unsatisfied 5 = satisfied)

7. The doctor was:

(1= unpleasant 5 = courteous)

8. The doctor's explanation of
your illness and treatment was:

(1= unsatisfactory 5 = satisfactory)

9. Were you satisfied with the
medical treatment you received?

(1= unsatisfied 5 = satisfied)

10. Do you believe that the fees are appropriate for services rendered?

11. Do you wish to be personally contacted about the quality of care we have provided?

Name (optional)

Phone (optional)

Additional Comments:

Thanks again for filling out this questionnaire.

East Lansing Orthopedic Association

517-394-3200

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Privacy Policy & Procedures

2009 East Lansing Orthopedic Association PC. All Rights Reserved

Updated: 4/17/09

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3394 E Jolly Road, Suite A Lansing, MI 48910 * Phone (517) 394 - 3200 * Fax (517) 394 - 4250