Patient Satisfaction Survey:

We want to be sure we are doing everything we can to serve you. Please take a minute to fill out this survey.
All responses are confidential, and we don't want you to sign it or otherwise indicate your name. Just let us
know what to do better!

Thank you.

On a scale from 1 to 5, with 5 being excellent and 1 being poor, how would you rate:

The time between your call to schedule an appointment and your appointment date? Did we fit you in fast enough? Poor 1 2 3 4 5 Excellent
Comments:
The time it took us to answer your call? Poor 1 2 3 4 5 Excellent
Comments:
The manners of the person(s) who scheduled your appointment? Poor 1 2 3 4 5 Excellent
Comments:
I was greeted and checked in quickly? Poor 1 2 3 4 5 Excellent
Comments:
The wait time to see the Doctor? Poor 1 2 3 4 5 Excellent
Comments:
The convenience of our office locations? Poor 1 2 3 4 5 Excellent
Comments:
The professionalism and helpfulness of your reception. Was the receptionist polite? Were your questions answered? Poor 1 2 3 4 5 Excellent
Comments:
Staff kept me informed of wait times? Poor 1 2 3 4 5 Excellent
Comments:
The comfort, cleanliness and amenities of the reception? Poor 1 2 3 4 5 Excellent
Comments:
Your doctor: Dr. Allen Chu
The amount of time spent with your physician? Poor 1 2 3 4 5 Excellent
Comments:
His or her listening? Poor 1 2 3 4 5 Excellent
Comments:
His or her explanation of procedures, diagnoses, or treatment regimen? Poor 1 2 3 4 5 Excellent
Comments:
His or her "bedside manner"? Poor 1 2 3 4 5 Excellent
Comments:
If you have visited our practice before, how convenient did you find: Prescription refills (if appropiate)? Poor 1 2 3 4 5 Excellent
Comments:
Getting lab results (if appropiate)? Poor 1 2 3 4 5 Excellent
Comments:
Overall, how would you rate our practice? Poor 1 2 3 4 5 Excellent
Comments:
Additional Comments:
Suggestions for Improvement:
* Information below not required but we would like to contact you if you have an issue or concern that needs to be addressed.
Patient Name:
Phone #: