LinkedInThis field is for validation purposes and should be left unchanged.Patient's Name (Optional) First Last Physician's NameDate of Visit MM slash DD slash YYYY 1. Were you able to schedule an appointment within a reasonable amount of time? Yes No2. Was the staff at check-in courteous and helpful? Yes No3. How satisfied were you with the wait time in the waiting room? Completely Satisfied Satisfied Dissatisfied4. What do you feel is an appropriate amount of time to wait in a waiting room? 0-15 minutes 15 minutes – 30 minutes 30 minutes – 45 minutes More than 45 minutes Any amount of time5. Was the clinical staff courteous and helpful? Yes No6. How satisfied were you in our presentation of information regarding your treatment plan, medications and/or follow-up care? Completely Satisfied Satisfied Disssatisfied7. How satisfied were you with the care provided by your physician? Completely Satisfied Satisfied Dissatisfied8. If it was necessary for you to schedule additional tests or surgery, were you satisfied with our assistance? Yes No Not Applicable9. If you had a question about your bill today, was the office staff able to direct you? Yes No Not Applicable10. Have you contacted our billing office? Yes No10.1 Was the billing staff professional and courteous? Yes No10.2 Were you quickly directed to someone that could assist you? Yes No10.3 Were you satisfied with the time it took to resolve your concern? Yes No10.4 How satisfied were you with how your questions or concerns were addressed? Completely Satisfied Satisfied Dissatisfied10.4.1 How could the billing office have more effectively met your needs?11. Would you refer your family member, friend, or coworker to OrthoSports? Yes No12. If your answer to any of the above questions was “No,” please provide feedback on how we can improve our service to you.13. Additional Comments or Suggestions For any inquiries, please do not hesitate to contact us online or request an appointment today. We are here to assist you.
