PATIENT SATISFACTION SURVEY

Instructions: Please select one Response for each of the following questions:

1. Are you a new patient or returning patient?
New Patient Returning Patient
2. It was easy to schedule your office appointment.
N/A Best Good So-So Bad Worst
3. Appointments were available within a reasonable period of time.
N/A Best Good So-So Bad Worst
4. (New patients only) When you called to schedule your first appointment, the person you spoke to was friendly and professional.
N/A Best Good So-So Bad Worst
5. (Returning patients only) Your calls to your doctor's secretary were handled professionally and with courtesy.
N/A Best Good So-So Bad Worst
6. The 'New Patient Brochure' was informative and helpful.
N/A Best Good So-So Bad Worst
7. If you accessed our web site (www.ing.md) you found it to be informative and attractive.
N/A Best Good So-So Bad Worst
8. When you arrived in the waiting room today, the receptionist was courteous and friendly.
N/A Best Good So-So Bad Worst
9. The check-in process was efficient.
N/A Best Good So-So Bad Worst
10. You were seen on time by your physician or healthcare professional when you arrived at our office today.
N/A Best Good So-So Bad Worst
11. Our staff informed you if there was a delay in being seen.
N/A Best Good So-So Bad Worst
12. The person who took your blood pressure and took you to exam room today was professional and friendly.
N/A Best Good So-So Bad Worst
13. While in the exam room today, our clinical and nursing staff were friendly and sensitive to your needs and concerns.
N/A Best Good So-So Bad Worst
This question is required. You must answer it to turn in the survey 14. Your doctor or health care provider met your expectation(s) for your office visit today.
N/A Best Good So-So Bad Worst
15. The staff member who coordinated your appointments for testing or future office visits was helpful and friendly.
N/A Best Good So-So Bad Worst
16. The staff member who scheduled you for surgery was helpful and friendly (may be the person same as 15 above).
N/A Best Good So-So Bad Worst
17. The check-out process was efficient, and the staff person was professional and friendly.
N/A Best Good So-So Bad Worst
18. Please rate your overall experience for your visit today.
N/A Best Good So-So Bad Worst
This question is required. You must answer it to turn in the survey 19. You would recommend our practice to others.
N/A Best Good So-So Bad Worst
Are you willing to provide a testimonial about the medical care you received from us?
Yes No
Enter Comments:
What kind of comment is it?
General Suggestion Complaint
This question is required. You must answer it to turn in the survey Select the physician or healthcare professional you saw today.
PHYSICIANS ACKERMAN, LAURIE MD BOAZ, JOEL MD CALLAHAN, JAMES MD COHEN-GADOL, AARON MD CRECELIUS, JEFFREY MD DORAN, CHRIS MD FULKERSON, DANIEL MD GEHRING, RANDY MD GIANARIS, PETER MD HORN, ERIC MD JAMES, STEVEN MD KHAIRI, SAAD MD LEIPZIG, TOM MD LIPSON, NANCY MD MCCANNA, SHANNON MD MELAMED, ITAY MD MILLER, JAMES MD MOBASSER, JEAN-PIERRE MD NELSON, PAUL MD PAYNER, TROY MD POTTS, ERIC MD PRITZ, MICHAEL MD RODGERS, RICHARD MD SARTORIUS, CARL MD SHAH, MITESH MD SHAPIRO, SCOTT MD SMITH, JODI PHD, MD THOMAN, JAMES MD TURNER, MICHAEL MD VITTO, JOSE MD WILSON, DERRON MD WITT, THOMAS MD WORTH, ROBERT MD YOUNG, RON MD NURSES AND PHYSICIAN ASSISTANTS ANDERSON, AMY NP ASH, DENISE NP BARTON, MARK PA BEDWEL, CHERYL RN BELL, STACY NP BRYANT, KIM NP BUTZ, KATHY RN CRAFT, ROBERTA PA CRISWELL, EMBER RN DOBSON, JAIME PA ELEFTHERI, JILL PA GROVE, KAREN NP HAGY, SHANNON RN HALPERN, KRISTIN PA HOLE, IDA NP HOSS, GLORIA NP KAY, SANDRA NP KOERS, JESSIE NP LEMASTERS, STACY NP LEVINE, ELLIOTT PA WHITFIELD, DENISE RN Don’t know/don’t remember OTHER   RESIDENT
Date Of Visit:
Patient Name (Optional):
Patient Phone (Optional):
This question is required. You must answer it to turn in the survey Select the office where you were seen today?
Clarian North Clarian West Community North Greenwood Indiana Cancer Pavilion IU Hospital and Outpatient Center Lafayette Lebanon Methodist Regenstrief Health Center at Wishard Hospital Riley Hospital for Children St. Vincent Don't Know

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