Patient Survey

Patient Feedback Form

* Indicates required field

Check Which Applies: *

Compliment Suggestion Complaint

Which Office did you visit? *

New Paltz Pleasant Valley

Your Name (Optional): *

Name Of Employee Who Worked With You (Optional) *

Date You Visited Us: *

Please describe your feedback and include any pertinent information: *

How long was your wait time before speaking with a team member in our office? *

20 minutes or longer 15-19 minutes 10 minutes Helped immediately

How well did you feel our Team Member understood what you were saying? *

Completely Slight misunderstanding Not well at all

How eager to help you was our Team Member? *

Extremely Eager Moderately Eager Not at all Eager

How quickly did our Team Member solve your problem or answered your questions? *

Very Quickly Somewhat Quickly Very Slowly

How knowledgeable did our Team Member seem to you? *

Extremely knowledgeable Moderately knowledgeable Not at all knowledgeable

Overall was your Experience with our office better then you expected, worse or about what you thought it would be? *

A great deal better About what was expected A great deal worse

Submit

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