Patient
Survey
 
Our goal is to offer the best possible care and make certain your visit with us meets your needs.  You will help us do that by completing this short confidential questionnaire.  By following the Patient Cycle of Service, please rate our performance for each area.  We appreciate your written comments immensely!  

 

 

 

 

 

 

1 Poor         2 Below Average        3 Average         4 Above Average         5 Excellent

1 2 3 4 5 Comments/Recommendations
  Phone Representation
Making an Appointment
Reception Area
Check In
Waiting in the Reception Area
Escort to Exam Room
Waiting in Exam Room
Provider Interview/Exam
Allergy Services
Checking Out
Billing/Insurance
Web Site
Other/Recommendations
Should the Staff Wear Name Tags? Yes     No



Name (Optional)

Phone (Optional)
E-mail Address
(Optional)

    

Patient Cycle of Service developed by The Bradford Company, 2001
Denver, CO 80206     °     (303) 832-5776     °     VJBradford@prodigy.net

 
   


  Alexandria
  6355 Walker Lane, Suite 308
  Alexandria, VA 22310
  703-313-7700 (T) - 703-313-0178 (F)