Form - New Client Survey Form

New Client Information
Name
First Name
Last Name
E-Mail Address (required) :
How did you hear about us? (required)
referral
website
yellow pages
open house
P.A.S.S Program
drive by
other
How was your first experience?
Front Desk Staff
Were you greeted within 3 seconds of entering the building? (required)
yes
no
Was the front desk member who assisted you knowledgable and friendly? (required)
yes
no
Were your questions answered satisfactorily by the front desk staff? (required)
yes
no
Waiting Time/Doctor
How long was your wait time to see the doctor? (required)
less than 5 mintues
5-15 minutes
more than 15 minutes
Was the technician assisting the doctor friendly and helpful? (required)
yes
no
Was the doctor friendly and courteous? (required)
yes
no
Were all of your questions and concerns answered satisfactorily by the doctor? (required)
yes
no
Were all procedures explained to you by the doctor? (required)
yes
no
sort of, but I still wasn't sure what to expect
Did the doctor explain all 'at home' or 'follow-up' care to you? (required)
yes
no
sort of, but I still had questions
Take Home Items
Did you receive all medications prescribed by the doctor when you left our office? (required)
yes
no
no, but I declinded some of them
n/a
Do you feel you received an adequate number of informational handouts to help you? (required)
yes
no
n/a
Return Visits
Will you be returning to our hospital? (required)
yes
no
maybe
Would you refer a friend to our hospital? (required)
yes
no
maybe
Comments
Please write any comments you may have below.


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