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SURVEY
Other
Patient Satisfaction Survey
Measure patient experience across care, wait times, and communication.
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Preview — how respondents will see this form
Overall, how satisfied were you with your visit?
*
The staff treated me with courtesy and respect.
*
3
Strongly Disagree
Strongly Agree
How long did you wait to be seen?
*
Under 15 minutes
15–30 minutes
30–60 minutes
Over an hour
The provider explained things in a way I could understand.
*
3
Strongly Disagree
Strongly Agree
How likely are you to recommend our practice?
*
0
1
2
3
4
5
6
7
8
9
10
Not at all likely
Extremely likely
How could we improve your experience?
Long answer…