Pri Med Physicians, Inc.

Dear Patient :

Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all of our patients.

We would like to know how you feel about our medical services, our patient-handling systems, our physicians and staff members.

Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs.

Thank you.

Your Name:
* Date of Service: (required)
* Facility you visited: (required)

PLEASE RATE THE FOLLOWING:

A. PRIOR TO YOUR VISIT:	Excellent	Very Good	Good	Fair	Poor	Does Not Apply
1. Your first impression
2. The efficiency of the check-in process
3. Waiting time in the reception area
4. Where the bathrooms and reception area clean
5. Waiting time in the exam room

B. OUR STAFF:
1. The courtesy of the person who took your call.
2. The friendliness and courtesy of the patient registration staff.
3. The caring concern of our clinical staff (medical assistants, LPN's, X-Ray Techs).
4. The cleanliness and comfort of our exam rooms
5. The helpfulness of the people who assisted you with billing or insurance questions.

C. YOUR VISIT WITH THE DOCTOR:
1. Explaining things in a way you could understand.
2. Instructions regarding medication/follow-up care.

D. OVERALL:
1. How would you rate your overall visit

WOULD YOU RECOMMEND THE DOCTOR TO OTHERS?	Yes	No

IF NO, PLEASE TELL US WHY?

IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

Thank you again, your comments and suggestions are very important to Pri Med Physicians!

Medfusion