Fairhaven OBGYN Patient Satisfaction Survey

Fairhaven Obstetrics and Gynecology, Inc.

Dear Patient: Please choose the provider you saw from the list below and tell us your opinion about the service you received. Your responses will be kept strictly confidential. Thanks for your help.

Name:
Email: Provider Seen:

PLEASE RATE THE FOLLOWING:

Excellent

Very Good

Good

Fair

Poor

Does
Not Apply

A. YOUR APPOINTMENT:

1. Ease of making appointments by phone

N/A

2. Appointment available within a reasonable amount of time

N/A

3. Getting care for illness/condition as soon as you wanted it

N/A

4. Getting after-hours care when you needed it

N/A

5. The efficiency of the check-in process

N/A

6. Waiting time in the reception area

N/A

7. Waiting time in the exam room

N/A

8. Keeping you informed if your appointment time was delayed

N/A

9. Ease of getting a referral when you needed one

N/A

B. OUR STAFF:

1. The courtesy of the person who took your call

N/A

2. The friendliness and courtesy of the receptionist

N/A

3. The caring/concern of our nurses/medical assistants

N/A

4. The helpfulness of the people in our business office

N/A

C. OUR COMMUNICATION WITH YOU:

1. Your phone calls answered promptly

N/A

2. Getting advice or help when needed during office hours

N/A

3. Explanation of your procedure (if applicable)

N/A

4. Your test results reported in a reasonable amount of time

N/A

5. Effectiveness of our health information materials/pamphlets

N/A

6. Our ability to return your calls in a timely manner

N/A

7. Your ability to contact us after hours

N/A

8. Your ability to obtain prescription refills by phone

N/A

D. YOUR VISIT WITH THE PROVIDER:
(Doctor, Midwife, Nurse Practitioner)

1. Willingness to listen carefully to you

N/A

2. Taking time to answer your questions

N/A

3. Amount of time spent with you

N/A

4. Explaining things in a way you could understand

N/A

5. Instructions regarding medication/follow-up care

N/A

6. The thoroughness of the examination

N/A

7. Advice given to you on ways to stay healthy

N/A

E. OUR FACILITY:

1. Hours of operation convenient for you

N/A

2. Overall comfort

N/A

3. Adequate parking

N/A

4. Signage and directions easy to follow

N/A

F. YOUR OVERALL SATISFACTION WITH:

1. Our practice

N/A

2. The quality of your medical care

N/A

3. Overall rating of care from your personal doctor or nurse

N/A

WOULD YOU RECOMMEND THE PROVIDER TO OTHERS? Yes No

IF NO, PLEASE TELL US WHY:

HOW DID YOU HEAR ABOUT OUR OFFICE?

Friend/family	Referral	Health Fair
Newspaper	Yellow Pages	Other

IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

SOME INFORMATION ABOUT YOU:

YOUR AGE:
Under 18
18 - 30
31 - 40
41 - 50
51 - 60
Over 60

ARE YOU:
A new patient
A returning patient