Patient Satisfaction Survey

Please Rate The Following

  • 5 Exellent
  • 4 Very Good
  • 3 Good
  • 2 Fair
  • 1 Poor

If you’ve chosen the all 5’s option, there’s no need fill out the ratings portion of this survey unless there are portions that you would like to specify an option other than ‘5’.

    A. Your Appointment:

    Ease of making appointments by phone

    54321

    Appointment available within a reasonable amount of time

    54321

    Getting scheduled as soon as you wanted it

    54321

    Getting after-hours care when you needed it

    54321

    The efficiency of the check-in process

    54321

    Waiting time in the reception area

    54321

    Waiting time in the exam room

    54321

    Keeping you informed if your appointment time was delayed

    54321

    B. Our Staff:

    The courtesy of the person who took your call

    54321

    The friendliness and courtesy of the receptionist

    54321

    The caring concern of our nurses/medical assistants

    54321

    C. Our Communication With You

    Your phone calls answered promptly

    54321

    Getting advice or help when needed during office hours

    54321

    Explanation of your procedure

    54321

    Effectiveness of our health information materials

    54321

    Our ability to return your calls/emails in a timely manner

    54321

    Your ability to contact us after hours

    54321

    Your ability to obtain prescription refills by phone

    54321

    D. Your Visit With Dr. Gorin and Staff

    Willingness to listen carefully to you

    54321

    Taking time to answer your questions

    54321

    Amount of time spent with you

    54321

    Explaining things in a way you could understand

    54321

    Instructions regarding medication/follow-up care

    54321

    The thoroughness of the examination

    54321

    E. Our Facility

    Hours of operation convenient for you

    54321

    Overall comfort

    54321

    Adequate parking

    54321

    Signage and directions easy to follow

    54321

    F. Your Overall Satisfaction With

    Our practice

    54321

    The quality of your medical care

    54321

    Overall rating of care from your provider or nurse

    54321

    COMMEND THE PROVIDER TO OTHERS?

    YesNo

    If No, Please Tell Us Why:

    Is There Any Way We Can Improve Our Services To You, Please Tell Us About It:

    If You Visited Any Other Plastic Surgery Offices Please List Them Here(only if you feel comfortable):

    The following fields are optional(name and email)

    First Name

    Last Name

    Email

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