Patient Satisfaction Survey Basic Information Name Location * Waco Date of Appointment * Which Doctor Treated You? * Dr. Sappington Dr. Shah Dr. Avery Are you a New Patient or Established Patient? * New Patient Established Patient Staff Performance How close to your scheduled time did your appointment start? 0-15 minutes 16-30 minutes 31-45 minutes 46+ minutes How would you rate the performance and friendliness of the receptionist? 1 Star 2 Stars 3 Stars 4 Stars 5 Stars How would you rate the performance and friendliness of the medical assistant? 1 Star 2 Stars 3 Stars 4 Stars 5 Stars Physician Performance How would you rate the attitude of the physician? 1 Star 2 Stars 3 Stars 4 Stars 5 Stars How well did the physician explain your condition? 1 Star 2 Stars 3 Stars 4 Stars 5 Stars Overall Experience How would you rate the cleanliness of our office? 1 Star 2 Stars 3 Stars 4 Stars 5 Stars Would you recommend our practice to a family member or friend? Yes No What could we have done better? What else would you like to tell us about? reCAPTCHA
