Patient Satisfaction Survey



Please take a moment, and tell us about your most recent visit to our office. Your feedback provides us with the chance to see how we're doing, and how we can continue to improve. We greatly appreciate your feedback.

If you'd like us to contact you in regards to this survey, please fill out the following:

   Name:
   

   Phone Number:
   

   E-Mail: (required)
   


All of the following numbered questions are required!

1. Was this your first visit to Lakes Urgent Care?

a)Yes

b)No


2. Starting from the time you arrived, how long did you wait to see your health care provider?

a)15 minutes or less

b)16-30 minutes

c)31-45 minutes

d)46-60 minutes

e)more than 1 hour


3. Would you recommend us to your family and friends?

a)Very Likely

b)Somewhat Likely

c)Undecided

d)Not Likely

e)Not At All


4. How easy was it to find or locate Lakes Urgent Care?

a)Excellent

b)Very Easy

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


5. How did you hear about Lakes Urgent Care?

a)Driving by the building

b)Newspaper ad

c)Referred by your physician

d)Referred by a friend

e)Other:


6. The courtesy of the front desk/registration staff:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


7. The courtesy of the patient care staff:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


8. The care and concern shown for you as an individual by the physician:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


9. How well the physician explained my condition and treatment to me:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


10. The amount of time the physician spent with me was:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


11. The concern for your privacy:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


12. Your oversall satisfaction of this visit:

a)Excellent

b)Very Good

c)Satisfactory

d)Needs Improvement

e)Unsatisfactory


13. Please tell us if you have seen any of the following advertisements for Lakes Urgent Care (please check all that apply):

a)Yellow Pages Listing

b)Yellow Pages.com Listing

c)Web/Internet Search Listing

d)United Artists Theatres Ad

e)Local Youth Athletic or Arts Sponsorship

e)I have not seen any ads.


Tell us one thing that you feel we are doing well:

If you rated us other than "EXCELLENT", please explain how we could improve:


Thank You for allowing us to share in YOUR health care today.
YOUR opinion is valuable to us and all of your answers will be kept confidential.