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Strongly
Agree |
Agree |
Neutral |
Disagree |
Strongly
Disagree |
| 1.) |
When you called our office, your call was handled promptly and courteously. |
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| 2.) |
Your appointments were made within a reasonable time frame. |
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| 3.) |
The receptionist acknowledged and greeted you when you arrived. |
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| 4.) |
The waiting area was clean and comfortable. |
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| 5.) |
The medical staff (your nurse) was friendly and courteous. |
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| 6.) |
You received adequate time with the provider. |
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| 7.) |
You felt comfortable making comments and asking questions of your provider. |
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| 8.) |
The details of your treatment were explained to you in words you understood. |
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| 9.) |
You would recommend our providers to a co-worker or family member. |
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| 10.) |
Our providers have a good "bed-side" manner. (courteous, respectful, etc.) |
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| 11.) |
The time you waited to be seen by a provider was reasonable. |
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| 12.) |
Parking is convenient |
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| 13.) |
Getting lab results was timely. (if applicable) |
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| 14.) |
You received appropriate information about medications (if any) |
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| 15.) |
Insurance and billing personnel have been helpful (if applicable) |
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| 16.) |
You were pleased with your overall experience with our office. |
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| 17) |
Why did you choose The Women's Healthcare Group for your care? |
(check as many as apply) |
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Reputation for quality care |
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Location - close to home or office |
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Insurance required |
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Advertisement - (What Type?
TV
Radio
Magazine
Newspaper
Billboard) |
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Cost |
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Previous visit |
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Yellow pages |
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Referral - physician or family member / friend |
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Other
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| 18.) |
What is the most important thing we can do to improve our services? |
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| 19). |
Was there a specific staff member who went "above and beyond" to assist you? |
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Name of Staff Member:
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| 20.) |
At my last visit, I saw: |
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Physicians: |
Certified Nurse Midwives: |
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Dennis R. Johnson, MD |
Felicia Rohrbaugh, MSN, CNM |
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William M. Unwin, MD |
Deborah A. Brown, MSN, CNM |
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Kathryn K. Hassinger, MD |
Carol L. Landry, MSN, CNM |
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John J. Lawrence, MD |
Nurse Practitioner: |
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Meg K. Figdore, MD |
Holly A. Shearer, MSN, CRNP |
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Janet L. Ashby, MSN, CRNP |
| 21.) |
Date of my visit:
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| 22.) |
Your Age:
(
Under 18
18-25
26-45
46-55
56-70) |
| 23.) |
Additional Comments: |
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