Patient Satisfaction Survey


Location of your visit     Appointment with Dr.  
Date of your appointment     Are you a New or Established Patient
Please rate the statements below using the following scale:
1 Very Dissatisfied   2 Somewhat Dissatisfied   3 Somewhat Satisfied   4 Very Satisfied   NA Not Applicable
1 2 3 4 NA
1. Courteous and caring attitude of staff scheduling appointment
2. Effectiveness of check-in staff
3. Wait time before being seen by clinician/physician
4. Courteous and caring attitude of clinical staff (nurse, lab tech, x-ray tech)
5. Physician explained medical issues thoroughly
Comments:
Your Overall Experience:
6. Would you return to Mid-Atlantic Women’s Care, PLC?
7. Would you recommend Mid-Atlantic Women’s Care, PLC to your family and friends?
Required Contact Information:
Name*  
Contact Phone     or Email address