Welcome to New Image Dermatology - Patient Satisfaction Survey


Patient Survey
We value your opinion! PATIENT SATISFACTION SURVEY We are continually striving to provide you with the BEST patient care. Please share with us if you were happy with your visit or if there is a way, you feel, we can serve you better by answering the following questions regarding our service: (required fields are depicted with a ) Name* 1) What is the purpose of your visit to our office? * 2) Did you have an appointment? * Yes No 3) How long did you have to wait before you were seen by a doctor? * Please tell us how satisfied or dissatisfied you were with each of the following: 4) How satisfied were you with the way you were treated by the staff at our office? * Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied 5) How satisfied were you with the way you were treated by the nurse? * Undecided Somewhat Satisfied Very Satisfied Somewhat Dissatisfied Very Dissatisfied 6) How satisfied were you with the way you were treated by the doctor? * Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied 7) How satisfied were you with the way your questions were answered? * Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied 8) How would you rate the courtesy you were shown by staff at our office? * Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied Please tell us how much you agree or disagree with the following statements: 9) The staff was knowledgeable. * Strongly Disagree Disagree Undecided Agree Strongly Agree 10) The staff was friendly and courteous. * Strongly Disagree Disagree Undecided Agree Strongly Agree 11) The nurse was knowledgeable. * Strongly Disagree Disagree Undecided Agree Strongly Agree 12) The nurse was friendly and courteous. * Strongly Disagree Disagree Undecided Agree Strongly Agree 13) The doctor was friendly and courteous. * Strongly Disagree Disagree Undecided Agree Strongly Agree 14) My questions were answered fully. * Strongly Disagree Disagree Undecided Agree Strongly Agree 15) My visit to the office/clinic was a pleasant experience. * Strongly Disagree Disagree Undecided Agree Strongly Agree 16) Overall, would you say your visit to our office was very positive, somewhat positive, somewhat negative or very negative? * Very Positive Somewhat Positive Undecided Somewhat Negative Very Negative 17) What, if anything, did you like most about your visit to our office? 18) What, if anything, did you like least about your visit to our office? 19) Please tell us what, if anything, we can do to make future visits to our office more pleasant for you. Type the following: For security purposes, please type the letters in the image.
Privacy Statement \| Patient Bill of Rights For Questions and/or Concerns Please Contact the Administrator, Laura Richards, 727-847-3992.

We value your opinion!

PATIENT SATISFACTION SURVEY

We are continually striving to provide you with the BEST patient care. Please share with us if you were happy with your visit or if there is a way, you feel, we can serve you better by answering the following questions regarding our service: (required fields are depicted with a *)

Name

1) What is the purpose of your visit to our office? *

2) Did you have an appointment? *

Yes No

3) How long did you have to wait before you were seen by a doctor? *

Please tell us how satisfied or dissatisfied you were with each of the following:

4) How satisfied were you with the way you were treated by the staff at our office? *

Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

5) How satisfied were you with the way you were treated by the nurse? *

Undecided Somewhat Satisfied Very Satisfied Somewhat Dissatisfied Very Dissatisfied

6) How satisfied were you with the way you were treated by the doctor? *

Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

7) How satisfied were you with the way your questions were answered? *

Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

8) How would you rate the courtesy you were shown by staff at our office? *

Very Satisfied Somewhat Satisfied Undecided Somewhat Dissatisfied Very Dissatisfied

Please tell us how much you agree or disagree with the following statements:

9) The staff was knowledgeable. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

10) The staff was friendly and courteous. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

11) The nurse was knowledgeable. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

12) The nurse was friendly and courteous. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

13) The doctor was friendly and courteous. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

14) My questions were answered fully. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

15) My visit to the office/clinic was a pleasant experience. *

Strongly Disagree Disagree Undecided Agree Strongly Agree

16) Overall, would you say your visit to our office was very positive, somewhat positive, somewhat negative or very negative? *

Very Positive Somewhat Positive Undecided Somewhat Negative Very Negative

17) What, if anything, did you like most about your visit to our office?

18) What, if anything, did you like least about your visit to our office?

19) Please tell us what, if anything, we can do to make future visits to our office more pleasant for you.

Type the following:
For security purposes, please type the letters in the image.

Privacy Statement | Patient Bill of Rights

For Questions and/or Concerns Please Contact the Administrator, Laura Richards, 727-847-3992.