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DENT Neurologic Institute

For Patients

Patient Satisfaction Survey

How was your visit today?

Thank you for your visit to Dent Neurologic Institute. We need your input to enable us to provide the best quality of care to our patients. Please take a few minutes to fill out this questionnaire.

Please evaluate each area. Thank your for your cooperation!

* Denotes a required form field.

1. Reason for appointment: *

Appointment Information

2. Did the doctor have the appropriate information available at the time of your appointment? * Yes No

Overall Impression

3. Were you satisfied with your visit? * Yes No

4. Would you recommend Dent to family and friends? * Yes No

Please use the following scale to rate your satisfaction with the items listed below:

1 - N/A | 2 - Poor | 3 - Fair | 4 - Good | 5 - Excellent

Scheduling:

5. Appointment scheduled in a timely fashion 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

6. Courteous Telephone Staff 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

Registration:

7. Wait time for registration 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

8. Registration process 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

9. Polite Reception Area Staff 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

10. Waiting area clean & comfortable 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

11. Assistance with questions/forms 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

Clinic Operations:

12. Courteous & attentive provider 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

13. Exam performed professionally 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

14. Exam room clean & comfortable 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

15. Wait time kept to a minimum 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

16. Competent Clinical Support Staff 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

17. Professional Secretarial Staff 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

18. Prompt return of phone messages 1 - N/A 2 - Poor 3 - Fair 4 - Good 5 - Excellent

19. Other Comments:

Please keep your comments to 1,000 characters. If you would like to comment more than the limit will allow please feel free to call us or use our contact us form here. Thank you.

20. Primary Provider: *

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