PracticeBuilders - The nation's leader in healthcare-practice success since 1979

1. How often does your practice perform patient satisfaction surveys?
   • monthly
   • quarterly
   • annually
   • randomly
   • never
2. When a patient identifies a problem with your practice, do you…
   • act swiftly to correct the problem
   • make a note of it for future reference
   • ignore it and hope it goes away
   • assume the patient is wrong and discount the complaint
3. How would you rate your office staff on customer service?
   • worth their weight in gold, skilled and professional
   • not quite as good as I would like them to be
   • rough around the edges, in need of serious training
   • they need to be replaced as soon as possible
4. What incentives do you offer staff members who interact with patients?
   • they get to keep their jobs
   • periodic salary increases
   • bonuses for reaching agreed-upon performance benchmarks
5. How long does a patient typically wait to see you for an appointment?
   • 0-15 minutes
   • 15-30 minutes
   • 30-60 minutes
   • >60 minutes
6. Do you have a system in place for notifying patients in advance when you are running late?
   • yes
   • no
7. Do you routinely make eye contact with your patients during office visits?
   • yes
   • no
8. How much time do you personally spend with each patient during an office visit?
   • <10 minutes
   • 10-20 minutes
   • 30-45 minutes
   • 45-60 minutes
   • >60 minutes
9. When communicating with patients, do you typically use
   • clinical language
   • laymen's terms
   • combination of clinical and lay language
10. Do you consider yourself a good listener?
    • all the time
    • sometimes
    • never

Please provide the following information. Your survey results cannot be calculated without it.

^* Required

• ^*Name
• ^*Are you the practice owner
  • Yes
  • No
• If you're not the owner, what is your role in the practice?
• Practice Owner's Name
• Profession
• Specialty (if any)
• Practice Name
• ^*Address
• ^*City
• ^*State
• ^*Zip
• ^*E-mail
• ^*Phone
• ^*Fax
• Best time to call
• Best number to call
• Home Phone (optional)
• Cell Phone (optional)
• ^*Code

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