Patient Satisfaction Report Card

Help us provide you with the best possible care by responding to this short survey.

Which doctor did you see?

How did you hear about us? (Check all that apply)
 Newspaper Phone Book Advertisement Internet Site Insurance Directory Doctor Referral Friend/Relative Other

If you were referred by another doctor, what is the name of that doctor?

Please rate your level of satisfaction in the following areas:

The doctor's explanation of your medical problem
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The amount of time the doctor spent with you
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The doctor's level of concern for you and your problem
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The ease of making an appointment
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The friendliness and courtesy shown by the front office staff
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The length of time waiting to be seen
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The ease of scheduling your surgery in the office
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The level of professionalism in handling phone calls
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

The overall care provided to you
 Very satisfied Neither satisfied nor dissatisfied Not at all satisfied

How likely would you be to recommend Surgical Associates of West Florida to a friend?
 Very likely No opinion Not at all likely

How can we improve our services in the future?

What is your age?
 < 18 18–65 66 or older

Sex
 Male Female