| General Questions: |
| Which physician did you see today? |
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| When did you see the physician? |
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How did you hear about us?
Physician Referral Family/Friend Television Signage
Telephone Book Newspaper Magazine Community Events
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| Did you have any trouble locating the physician's office upon entering the clinic? |
Yes No |
| Reception/Scheduling: |
| Are our phones answered promptly? |
Yes No |
| Was your hold time minimal? |
Yes No |
| Was the receptionist courteous and helpful? |
Yes No |
| Did you receive a reminder call about your appointment? |
Yes No |
| Were you informed prior to your appointment of any pre-payment requirements? |
Yes No |
| Was the waiting area neat and clean? |
Yes No |
| Did receptionist verify your address and insurance upon arrival for appointment? |
Yes No |
| Was the availability of appointment reasonable? |
Yes No |
| How long was the wait time? |
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| Nurse/Clinic Staff: |
| Was nurse courteous, helpful and compassionate? |
Yes No |
| Was your phone call returned in a timely manner? |
Yes No |
| Did you receive your test results in a timely manner? |
Yes No |
| Did nurse demonstrate good clinical explanations and skills? |
Yes No |
| Physician: |
| Was the amount of time the doctor spent with you adequate? |
Yes No |
| Did he/she take time to answer your questions? |
Yes No |
| Did the physician provide the information you needed to understand your care? |
Yes No |
| Was the physician friendly, personable, and concerned? |
Yes No |
| Was the wait time in the exam room adequate? |
Yes No |
| Additional Comments |
| Would you refer your family or friends to Highland Clinic? |
Yes No |
Comments:
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Please provide us with your name and number if you would like our Administration to discuss your opinions in more detail
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