Health Care Evaluation

We would like to get your feedback on your most recent doctor visit.
Name of Doctor you visited
When you first located this doctor, how long did you have to wait for an appointment?
After you checked in on the appointment day, how long did you have to wait before seeing the doctor?
Please rate our staff helpfullness during your visit.
Very HelpfulHelpfulNeutralSomewhat HelpfulNot Helpful at All
Was the person who answered the phone and scheduled your appointment helpful?
Was the office staff helpful with your referral and insurance requirements?
Were the staff members that checked you in helpful and polite?
Was the nurse courteous and helpful?
Please rate the doctor that you were seeing.
ExcellentGoodFairPoor
Amount of time doctor spent with you
Doctor’s explanation of what was done for you (ie: tests, diagnosis, treatment)
Doctor’s personal manner (courtesy, respect, sensitivity)
Doctor’s answers to all your questions
Doctor’s instructions regarding medications & follow-up
Overall, how satisfied are you with the quality of care you received?
How likely are you to recommend the doctor to your friends and relatives?
Please complete the required fields.