Patient Satisfaction Survey

Date of this visit:

Physician Seen:*

Location/Facility Recently Visited*

1. Was the reception staff courteous and helpful?
YesNo

2. Was the nursing staff professional and courteous?
YesNo

3. Did the nursing staff answer your questions?
YesNo

4. Was the physician professional and informative?
YesNo

5. Did you feel the physician spent enough time with you?
YesNo

6. Did you feel the physician listened to your concerns?
YesNo

7. Did the staff respect your privacy?
YesNo

8. Was scheduling your appointment or procedure easy?
YesNo

9. Were explanations adequate and understandable?
YesNo

10. Was the area clean and comfortable?
YesNo

11. Would you recommend us to family or friends?
YesNo

12. Have you ever referred a friend/family member to your doctor?
YesNo

Overall, how do you feel about the quality of care you received and the services provided?
SatisfiedNeutralDissatisfied

Enter the code shown above

Submit

* Required

If you would like to record additional comments, please call our programmed phone line, 405-713-4426.
Thank you for assisting us in our continual effort to improve our services!

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