Patient Survey


Dear Patient,
In advance thank you for taking a moment to complete our survey. Our practice is extremely interested in providing the best care possible. Your input is greatly respected and your feedback will allow us to focus on any areas that may need improvement. All of your responses will remain confidential.
1. Which physician did you see during your visit?

Dr. Welsh Dr. Chmielewski
2. How did you learn about our practice?
Physician referral
Friend or relative
Another patient
Beaumont Referral Line
Other
3. Where you a “New” patient or an “Established” patient for your visit today?
New Established
4. When you called for your appointment, was the office staff courteous, efficient and helpful?
Yes No
5. Were you able to get an appointment day / time which was convenient for you?
Yes No

If “No” please explain:
6. How many days did you have to wait for an appointment?
1-3 days 4-6 days 7-10 days +10 days
7. Did you require a specific day / time / location for your appointment?
Yes No
8. What was the first thing you liked about our office?
9. Was there anything you disliked?
10. Approximately how long did you wait, after you scheduled appointment time, in the
reception area?
Minutes
11. How long did you wait in the exam room?

Minutes
12. Was the physician courteous and respectful?
Yes No
13. Did the Physician answer all of your questions and concerns during the visit?
Yes No

14. Please rate the following items on the scale provided:
(3) Good (2) Fair (1) Needs improvement
Adequate parking
Office appearance
Courteousness of staff
Wait to be seen
Answers to your questions
Explanation of treatment / procedures
Explanation of fees
Promptness with which your phone calls are returned
If you had surgery
Treatment during your hospital stay
15. Please rate our practice ( 0-10 scale , 10 being the best)
We would appreciate any other comments which would help us improve our service:
 
 
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