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Patient Satisfaction Survey — Rural Health Clinic
Items below designated with an asterisk (
*
) are required.
Requested By:
Your Name:
First:
Last:
Your Phone #:
Use the following format (XXX) XXX-XXXX
New or Existing Patient:
*
New
Existing
:
*
Make or Serial # (as applicable):
Date of Service:
*
(mm/dd/yyyy format)
Clinician Name:
Unknown
Access, Delivery and Service
Yes
No
N/A
1
I received an appointment in a timely fashion.
Reason:
Update Reason
2
The person who answered the phone and made the appointment was courteous and helpful.
Reason:
Update Reason
3
The wait time to be seen by a provider was timely.
Reason:
Update Reason
4
The services I received were appropriate and addressed my needs.
Reason:
Update Reason
5
My appointment needs were handled in a confidential and professional manner.
Reason:
Update Reason
6
My medical questions were answered and addressed in a way that I understood.
Reason:
Update Reason
7
I have been informed and understand my diagnosis.
Reason:
Update Reason
8
I have been informed of and understand the treatment plan.
Reason:
Update Reason
9
All of the staff that I interacted with treated me respectfully and professionally.
Reason:
Update Reason
10
I was 100% satisfied with my overall experience and the health services provided.
Reason:
Update Reason
COMMENTS:
We greatly appreciate your input. We use patient satisfaction survey reports to help us improve our day-to-day services. Please take an extra minute to provide details for your survey responses in the box below.
Question:
You answered, "No" for the question shown above. Using the text box below, please provide the details as to why you answered, "No".
Please provide your details in the text box above and then click the "Save" button below.
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