Patient Satisfaction Survey
Southwest Oral Surgery
It is our practice philosophy to continually look for ways to improve the quality of care we provide to patients. Please rate the following items according to your experience with our office. Additional comments are greatly appreciated. Please return this form to our office by using the submit button.
RANKING 5=Excellent 4=Very Good 3=Average 2=Fair 1=Poor
| Rating | ||
PATIENT SCHEDULING & RECEPTION |
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| - Phone etiquette (professionalism, courteousness) | ||
| - Amount of time spent waiting on “hold” | ||
| - Ease of scheduling your appointment | ||
OFFICE APPEARANCE AND PATIENT COMFORT |
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| - Office is comfortable and pleasant to be in | ||
| - Staff members courteous and professional | ||
| - Staff members responsive to patient’s needs | ||
TREATMENT |
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| - Treatment procedures and diagnosis were explained and understandable | ||
| - Doctor provided alternative care options | ||
| - Doctor and staff spent enough time with you | ||
FINANCIAL |
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| - Billing and insurance explanation or assistance | ||
| - Check out and payment process | ||
OTHER |
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| - Would you feel comfortable in recommending us to family or friends |
Name of doctor that provided your care:
Names of staff members that assisted in your care:
We welcome your ideas, suggestions and comments on how we are doing and what we can do to make our patients’ visits more enjoyable:
Would you like to be contacted regarding your comments?
If yes print the number where you may be reached:
THANK YOU FOR YOUR ASSISTANCE