Park Avenue Medical Patient Survey Form |
Please Give Us Your Feedback!
In an effort to better serve our patients, the staff and physicians would like to invite you to offer some feedback. Please help us to prioritize which area(s) we can improve to better take care of you. Thank you for your time. Your opinion is very important to us!
How would you rate the following aspects of our office? Please assign a number on a scale from 1 to 10 where "1" represents "Needs a lot of improvement" and "10" represents "Perfect as is".
1 2 3 4 5 6 7 8 9 10
Poor - Satisfactory - Great
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| 1. Telephone System: |
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| 2. Check-in / Registration Process: |
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| 3. On Time for Appointment: |
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| 4. Check-out: |
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| 5. Referral Process: |
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| 6. Prescription Refill Process: |
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| 7. Overall Opinion of Staff: |
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| 8. Overall Opinion of Office: |
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| 9. Level of Health Care You Receive: |
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| 10. Website: |
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| 11 Your doctor (please select) |
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| Additional Comments: |
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| The security word is:doctor |
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