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Patient Survey
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Patient Survey
Patient Survey
Name (optional)
First
Last
Date Of Visit:
*
MM slash DD slash YYYY
Physician Seen:
*
Lloyd C. Briggs, Jr., MD, MS
Grace R. Dasari, MD
Frank F. Fumich, MD
Steven P. Haman, MD
Mark G. McDonald, MD
Joseph R. Mission, MD
Michael J. Muha, MD
James M. Nieman, MD
James A. O'Neill, MD
Sam M. Patel, MD
James J. Patterson, MD
William A. Sanko, MD
Gary M. Schniegenberg, MD
Michael J. Wieser, MD
Office Location
*
Lima
Bluffton
Coldwater
Delphos
Kenton
Ottawa
Paulding
St. Marys
Van Wert
1. Was you call to our office answered promptly and efficiently?
Yes
No
If no, please explain
2. Did we respond to you in a friendly manner?
Yes
No
If no, please explain
3. On your appointment day, how were you treated by the staff?
4. How long did you wait in our office?
5. Did the physician spend enough time with you answering all your questions and explaining your condition?
Yes
No
If no, please explain
6. How could we have made the visit more beneficial to your particular needs?
7. On a scale of 1-10 (10 being the highest) please rate our staff on the day of your appointment. Please feel free to make additional comments.
Reception:
1
2
3
4
5
6
7
8
9
10
Clincial Staff
1
2
3
4
5
6
7
8
9
10
Doctor
1
2
3
4
5
6
7
8
9
10
X-Ray/MRI Techs:
1
2
3
4
5
6
7
8
9
10
Overall:
1
2
3
4
5
6
7
8
9
10
8. How did you hear about our office?
Physician Referral
Friend or Family Referral
Newspaper
Television Ad
WebSearch
Other
If other, please specify
9. Would you recommend our office to others?
Yes
No
If no, please explain
10. Any additional comments to better serve our patients are welcomed:
Name
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