Patient Satisfaction Survey

ALL ANSWERS ARE STRICTLY CONFIDENTIAL

Dear Patient, At Elmquist Eye Group, we want to provide the finest medical care possible in the most comfortable enviroment. Please take a few moments to complete the following survey to help us better meet your eye care needs.
 
1. How long have you beeen a patient of Elmquist Eye Group?
Less than 1 year
1-2 years
3-4 years
Over 4 years
 
2. How were you referred to our practice?
Referred by another physician
Referred by another patient
Newspaper ad
Radio ad
Near home or place of business
Hospital
Insurance provider book
Other: 
 
3. Did you have difficulty getting an appointment?
Yes
No
 
4. If yes to above, please explain:
 
5. Did we provide adequate assistance in any questions you had regarding your insurance?
Yes
No
 
6. How were you treated when you called our office?
Extremely well
Courteously
Impolitely
 
7. How long did you spend waiting past your scheduled appointment to see the doctor?
My appointment was on time
Less than 15 minutes
15 to 30 minutes
More than 30 minutes
 
8. If you waited more than 15 minutes were you given an explanation for the delay?
Yes
No
 
9. Please provide any comments you may have regarding the explanation of the delay:
 
10. During your visit, how were you treated by the BUSINESS STAFF?
Professionally
Pleasantly
Indifferently
Rudely
 
11. During your visit, how were you treated by the MEDICAL STAFF?
Professionally
Pleasantly
Indifferently
Rudely
 
12. Are your phone calls handled in a prompt, courteous manner?
Always
Most of the time
Never
 
13. Please indicate your satisfaction in the following areas: 1= Satisfied 2= Neutral 3= Dissatified
1 2 3
Location
Check-in
Cleanliness
Staff
Check-out
Parking
 
ABOUT THE DOCTOR
 
14. How interested did the doctor seem to be in your needs?
Always interested and concerned
Usually interested and concerned
Somewhat indifferent
Never has enough time for me
 
15. During your office visits, is your condition and treatment explained adequately?
Yes
No
 
16. If no to previous question, how can we improve?
 
17. Does the doctor adequately answer questions?
Yes
No
 
18. If no to previous question, how can we improve?
 
19. Were you given printed material to better explain your diagnosis or treatment?
Yes
No
 
20. Were you satisfied with the treatment you received from the doctor and the medical staff?
Yes
No
 
21. Please provide any comments about the treatment you received from the doctor and the medical staff:
 
ABOUT OUR OPTICAL DEPARTMENT
 
22. Have you visited our optical department?
Yes
No
 
23. During your visit, how were you treated by the OPTICIAN?
Professionally
Pleasantly
Indifferently
Rudely
 
24. Were you satisfied with your purchase?
Yes
No

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Elmquist Eye Group of Southwest Florida
12670 New Brittany Blvd., Suite 102
Fort Myers, Florida 33907

Phone: (239) 936-2020
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