Patient Satisfaction Survey Form

Personal Details

Name

Treatment Information

Quality of Care

Rate the following aspects of your care on a scale from 1 (Very Unsatisfied) to 5 (Very Satisfied)
Likert Scale
12345
Friendliness and courtesy shown by Front Office Staff
1
2
3
4
5
Friendliness and courtesy shown by Nursing Staff
1
2
3
4
5
Doctor/Provider
1
2
3
4
5
Did the physician see you in a timely manner?
1
2
3
4
5
Explanation given about medical tests, procedures and treatment plan
1
2
3
4
5
Convenience of our office hours for you
1
2
3
4
5
When calling the office was the telephone answered promptly and courteously?
1
2
3
4
5
How would you rate our automated medical messaging services regarding appointments, etc?
1
2
3
4
5

Facilities and Environment

Rate the following on a scale from 1 (Very Unsatisfied) to 5 (Very Satisfied)
Likert Scale
12345
Cleanliness of Facility
1
2
3
4
5
Comfort of Exam Rooms
1
2
3
4
5
Ease of Access
1
2
3
4
5

How did you hear about Carolina Health Specialists?

Select One

Overall Experience

Rate your overall experience on a scale from 1 (Very Unsatisfied) to 5 (Very Satisfied)
Likert Scale
12345
How would you rate the overall care you received?
1
2
3
4
5

Additional Comments

Please share any other comments or suggestions to help us improve our services.