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Gynecology Pregnancy Patient Registration Forms Request an Appointment Request Lab Results Request Prescription Refill Spanish Only

Survey

PATIENT SATISFACTION SURVEY

THE ADLER CENTER FOR WOMEN'S HEALTH

PLEASE ANSWER EACH QUESTION

1. When you phoned the office, was your call handled promptly and efficiently?

	yes
	no

Name of Employee:

2. Did you find the office staff helpful and courteous?

	yes
	no

Name of Employee:

Nursing?

	yes
	no

Name of Employee:

Billing Office?

	yes
	no

Name of Employee:

3. How long did you wait to see the doctor or midwife?

In the waiting room?
	0 to 15 minutes
	16 to 30 minutes
	more than 30 minutes

Name of Provider seen:

In the examining room?
	0 to 10 minutes
	11 to 30 minutes
	More than 30 minutes

4. How well did the nurses explain your medical care and answer your questions?

	very well
	adequately
	did not explain

5. Did the physician or midwife take the time to answer your questions and explain things to your satisfaction?

	yes
	no

Comments:

6. Have you received our newsletter via your email?

	yes
	no

7. If you did, was it informative?

	yes
	no

8. What other information would you be interested in receiving through our newsletter?

9. Which office did you visit?

	Woodbridge
	Stafford

10. How would you rate the overall care you received at this practice?

	excellent
	good
	satisfactory
	poor

11. What changes would you suggest so that we can improve our care?

12. Would you recommend our office to a friend or family member?

Thank you for taking the time to fill out this survey. We realize your time is valuable and hope that your feedback will help us to improve our practice.

Any additional comments or services you would like to see at our offices:

Patient Name: (optional):

Woodbridge
703-680-5327

Stafford
540-659-0928

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