How would you rate our concern for your privacy?

Outstanding Good Adequate Needs improvement Poor N/A

How often have you visited [Tanner Clinic] within the past year?

First Visit 2-5 Visits More than 6

Scheduling Your Appointment

Did you schedule an appointment by phone or did you drop in?

Scheduled by Phone Dropped In

If you scheduled an appointment, did you have to wait longer than expected to get scheduled?

Yes    No

How easy was it to make an appointment by telephone?

Very easy Easy Fair Somewhat hard Very difficult

How long did you wait to speak to a scheduling staff member?

0 to 2 minutes 3 to 5 Minutes 5 to 7 minutes Longer

Was the person who scheduled your appointment courteous and helpful?

Very Courteous Courteous Average Somewhat Rude Rude

If you were seeking a referral to a specialist, was your request handled in a timely manner?

Yes No

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk?

Very Courteous Courteous Average Somewhat Rude Rude

How long did you wait in the reception area beyond your scheduled appointment time?

0 to 5 Minutes 5 to 20 minutes 20 to 40 minutes Other

How long did you wait in the exam room before the physician appeared?

0 to 5 minutes 5 to 20 minutes 20 to 40 minutes Other

The Nursing Staff

How would you rate the competence of the nurse who helped you?

Outstanding Good Adequate Needs Improvement Poor N/A

How would characterize the concern that the nurse showed for your problem?

Outstanding Good Adequate Needs Improvement Poor N/A

Did the nurse respond to your requests within a reasonable period?

Yes No

The Doctor

Were you able to see the doctor of your choice?

Yes No N/A

Did you feel that your doctor spent an adequate amount of time with you?

Yes No N/A

Mark the boxes that characterize the demeanor of your doctor:

Attentive Concerned Friendly Distracted Rushed Inconsiderate

How would you rate the competence of your doctor?

Outstanding Good Adequate Needs Improvement Poor N/A

Did you feel that your doctor’s examination was thorough?

Yes No N/A

Please rate the clarity of the doctor’s explanation of your condition and treatment options:

Outstanding Good Adequate Needs Improvement Poor N/A

How well did your doctor include you in healthcare decisions?

Outstanding Good Adequate Needs Improvement Poor N/A

Were your questions answered to your satisfaction?

Yes No N/A

Would you recommend this facility and its staff to your family and friends?

Yes No N/A

The Lab Staff

How would you rate the professionalism and competence of the person who took your blood and worked on your lab exam?

Outstanding Good Adequate Needs Improvement Poor N/A

If you received a lab exam, please indicate the type(s) of lab exam you received:

Blood test Breast Exam CT scan MRI X-ray Other

If you received a lab exam, was the service prompt, comfortable, and courteous?

Outstanding Good Adequate Needs Improvement Poor N/A

Our Facilities

What is your impression of our Clinic grounds regarding cleanliness?

Outstanding Good Adequate Needs Improvement Poor N/A

What is your impression of our check in area regarding cleanliness?

Outstanding Good Adequate Needs Improvement Poor N/A

What is your impression of our waiting area regarding cleanliness?

Outstanding Good Adequate Needs Improvement Poor N/A

What is your impression of our exam rooms regarding cleanliness?

Outstanding Good Adequate Needs Improvement Poor N/A

Patient Accounts

How satisfied are you with the filing of your insurance claims?

Outstanding Good Adequate Needs Improvement Poor N/A

How satisfied are you with the help you receive when you have questions about your account?

Outstanding Good Adequate Needs Improvement Poor N/A

Was the person who helped you with your account courteous and helpful?

Outstanding Good Adequate Needs Improvement Poor N/A

After hour care and weekend care

How easy or difficult is it to reach us after hours?

Outstanding Good Adequate Needs Improvement Poor N/A

How would you rate our answering service?

Outstanding Good Adequate Needs Improvement Poor N/A

When you see a physician in our practice other than your regular physician, how satisfied are you with the care you receive?

Outstanding Good Adequate Needs Improvement Poor N/A

Additional Feedback

Please list any areas in which our service could be improved. Type in the box below.

Please share any additional comments. Type in the box below.

Personal Information

Providing the following information is optional.

First Name: Last Name:

Address:

City: State:    ZIP Code:

Telephone: Gender: Age:

Would you like someone to contact you regarding your responses on this survey?

Yes No

Thank you for taking the time to fill out our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated.