How are we doing?

Would you please take a few minutes of your time to complete this survey? Our goal is to provide comfort, convenience and satisfaction, as well as the best medical care to all our patients. We would like to know how you feel about our medical services, our patient-handling systems and our physicians and staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs. Thank you!

Was this appointment for:
 OB Care 
 Gynecology Care 
 Annual Exam 
 Surgery 
 Post Partum Care 
 Other 

Was this appointment with:
 Dr. Joseph Santiago 
 Vicki Voegel, Physician Assistant 
 Jolene Hamann, Certified Nurse Midwife 
 Sonographer 
 Massage Therapist 
 Nurse 

Please select the most appropriate response for the following questions:
5-excellent 4-very good 3-good 2-fair 1-poor NA-not applicable

How satisfied were you with the…

Receptionist?
 5   4   3   2   1   NA 

Nursing Staff?
 5   4   3   2   1   NA 

Billing Staff?
 5   4   3   2   1   NA 

Sonographer?
 5   4   3   2   1   NA 

Massage Therapist?
 5   4   3   2   1   NA 

Please select the most appropriate response for the following questions:
5-excellent 4-very good 3-good 2-fair 1-poor NA-not applicable

How would you rate your appointments with us?

Available within a reasonable amount of time?
 5   4   3   2   1   NA 

Scheduled at a convenient time of day?
 5   4   3   2   1   NA 

Completed in a timely manner?
 5   4   3   2   1   NA 

Availability with provider desired?
 5   4   3   2   1   NA 

Please select the most appropriate response for the following questions:
5-excellent 4-very good 3-good 2-fair 1-poor NA-not applicable

During your appointment with our provider did you feel…

the provider listened to you?
 5   4   3   2   1   NA 

the provider answered your questions?
 5   4   3   2   1   NA 

the examination was thorough?
 5   4   3   2   1   NA 

the amount of time spent with you was appropriate?
 5   4   3   2   1   NA 

How did you hear about us?
 Family Member 
 Friend 
 Coworker 
 Radio 
 Yellow Pages 
 Website 
 Health Fair 

Please select the most appropriate response for the following questions:
5-excellent 4-very good 3-good 2-fair 1-poor NA-not applicable

How would you rate our facility?

Overall comfort of office?
 5   4   3   2   1   NA 

If not a 5, why?
 Cleanliness 
 Furnishings 
 Tempurature 
 Privacy 
 Layout 

Would you be interested in
 Spider vein removal 
 Cellulite reduction 
 Laser hair removal 
 Patient Educational Classes 
Other

Would you recommend our office to a friend?
 Yes 
 No 

If not, please tell us what would make you willing to recommend us?


Would you like to be contacted?
Yes
No

Name and Contact Information: