Patient Survey

Our goal is to provide you with the best possible medical care. Please take a moment to share your feedback with us. Your comments will be kept strictly confidential. Thank you for taking the time to help us. 

Required fields are marked with an asterisk (*)

1. Was this your first visit? *

2. Which doctor or practioner did you visit? *

3. Why did you decide to seek medical treatment at our office? Check all that apply. *







Please give us a grade in each of the following areas using the following grading scale: A=Excellent, B=Above Average, C=Average, D=Needs Improvement, F=Poor, NA=Not Applicable to My Visit 4. I was able to make an appointment promptly at a convenient time. *

5. The staff that helped me make an appointment was courteous. *

6. When I arrived the reception desk staff was helpful and courteous. *

7. The reception desk checked me in promptly. *

8. The waiting room was comfortable and clean. *

9. The wait time to see my physician was reasonable. *

10. The nurse was helpful and courteous. *

11. The X-Ray Department was helpful and courteous. *

12. The exam room was clean and comfortable. *

13. My Doctor or practitioner was interested in my problem. *

14. My Doctor or practitioner explained my illness and treatment. *

15. I was satisfied with the medical treatment I received. *

16. The staff that checked me out was helpful and courteous. *

17. My overall visit to The Spine Center. *

18. Comments:

19. What is your email address: *

20. Would you like to receive email updates from The Spine Center? *

21. May we use your comments on our website? *

If so, type your name as you would like it to appear in the blank.

For security reasons, enter the code shown below: *

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