Patient Satisfaction Survey

Patient Information

Please rate your level of satisfaction for the following:
5 = Very Satisfied | 4 = Satisfied | 3 = Unsatisfied | 2 = Extremely Unsatisfied | 1 = No Opinion

General Information

What type of patient are you? New PatientReturning Patient

Date of visit (required):

What type of visit was it? : Initial visitFollow-up visit

How did you hear about Agility Orthopaedics?--- Please Select One ---Friend/FamilyDoctor ReferralPhysical TherapistAdvertisementInternetBuilding signageInsurance websiteInsurance AdjusterWorkers’ Compensation Case ManagerAttorneyChiropractorOther

Scheduling

Telephone answered promptly: 54321

Knowledge of person answering call: 54321

Appointment scheduling process: 54321

Appointment time was convenient: 54321

Registration

Receptionist greeting: 54321

Check-in process: 54321

Check-out process: 54321

Visit

I was seen on time: 54321

I waited a reasonable amount of time: 54321

Approximately how long was your wait?:--- Please Select One ---Taken EarlyNo Wait1-15 minutes16-30 minutes31+ minutes

Staff

Provider (required): --- Please Select One ---Joshua P. Nadaud, M.D.Jason D. Rabenold, M.D.Sarah Fehringer, PA-CJennifer Richardson, PA-CNurse / Clinical StaffX-ray Staff

Family Doctor:

Overall comments:

Would you recommend us to others?: YesNoDon't Know

Thank you for your time and input.

All comments will remain confidential.