Patient Survey

Each member of our dedicated staff wants to provide the highest level of medical care and customer service for every patient. Your input is very important to us. Whether a rave review or maybe we could use a little improvement, your feedback is essential to our success. To help us improve every patient’s experience, please complete the form below.

First Name*

Last Name*

Email*

Gender*

Provider seen during visit:*

Were you on time for your appointment?*

What office did you visit?*

Friendliness of check-in staff:*

Your insurance benefits were verified and explained to you in a timely manner:*

Wait time to see provider:*

Cleanliness of the waiting room:*

Cleanliness of the examination room:*

Professionalism of provider and medical staff:*

Quality of information provided by provider:*

Quality of your physician’s communication skills:*

Were your expectations of this office visit met?*

Likelihood of recommending The Doctors Center to others:*

Likelihood of you returning to The Doctors Center for other medical needs:*

Overall rating of your experience:*

During your visit what areas can we improve in?

Additional Questions or Comments

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