St. Clair Specialty Physicians

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Our Core Values
- Quality
- Compassion
- Honesty
- Integrity
- Teamwork
- Respect
- Dignity
- Innovation
- Improvement

St. Clair Specialty Physicians Patient Satisfaction Survey

Dear Valued Patient:

In a continued effort to provide state-of-the-art patient centered care, your feedback becomes essential. We greatly appreciate you taking the time to complete this form with your thoughts impressions, and suggestions on how we can better serve you.

Sincerely,
The Physicians and Support Staff
St. Clair Specialty Physicians

DIRECTIONS: Please rate the services you received from our practice. Select option that best describes your visit. Please do not answer questions which do not apply to your visit. As always, your personal comments are appreciated.

* Denotes required field

Name:

Email:

Phone:

Date of visit:

(MM/DD/YYYY) *

Location:

A. YOUR APPOINTMENT	very poor	poor	fair	good	very good
1. Simplicity of scheduling your appointment
2. Courtesy of staff who scheduled your appointment
3. Promptness in returning your phone calls
4. Capability of getting an appointment when needed
Personal Comments:

B. YOUR VISIT	very poor	poor	fair	good	very good
1. Ease of parking
2. Courtesy of staff in the reception area
3. Comfort and appeal of the waiting area
4. Length of wait before going to an exam room
5. Comfort and appeal of the exam room
6. Responsiveness/courtesy of the nurse/assistant
7. Concern the nurse/assistant showed for your problem
8. Waiting time in exam room
Personal Comments:

C. YOUR HEALTHCARE PROVIDER	very poor	poor	fair	good	very good
1. Responsiveness/courtesy of your provider
2. Explanations the provider gave you about your care or circumstances
3. Concern the provider showed for your questions
4. Provider's consideration to include you in decisions about your treatment
5. Information the provider gave you about medications
6. Information the provider gave you about follow-up
7. Provider spoke with you using vocabulary you could understand
8. Provider spent appropriate time during visit
9. Likelihood of recommending your provider
Personal Comments:

D. MISCELLANEOUS	very poor	poor	fair	good	very good
1. Convenience of office hours
2. Our sensitivity to your needs
3. Our concern for your privacy
4. Ease of obtaining test results
5. Affordability of office visit
6. Acceptance of your medical health insurance
Personal Comments:

E. OVERALL EVALUATION	very poor	poor	fair	good	very good
1. Overall cheeriness of our practice
2. Overall cleanliness of our practice
3. Overall rating of care provided
4. Would you recommend our practice to a family or friend
Personal Comments:

Our Core Values

St. Clair Specialty Physicians Patient Satisfaction Survey