Patient Satisfaction Survey

Date of Office Visit	Office Location
Which provider did you see this day?
Please choose the number that best reflects your visit at Prince William OB-GYN for this date of service for each of the below questions. Use the folling scale: 5 = Excellent \| 4 = Above Average \| 3 = Average 2 = Below Average \| 1 = Poor If you rate any question less than a 4 or 5, please provide feedback on how we can improve.
How would you rate how SAFE you felt while visiting our office?
Comments about Safety
How would you rate the friendliness and helpfulness of the front desk?
Comments About Friendliness and Helpfulness of the Front Desk
How would you rate the waiting time to see the physician?
Comments About Waiting Time
How would you rate the comfort and cleanliness of the office?
Comments About Cleanliness of the Office
How would you rate the friendliness and helpfulness of the nursing staff?
Comments About Friendliness and Helpfulness of the Nursing Staff
How would you rate how well your questions and concerns were addressed?
Comments About Addressing of Questions and Concerns
How would you rate the time that the physician spent with your problems?
Comments About Time Spent With Physician
How would you rate the convenience of the office hours for you and your family?
Comments About Office Hours
How would you rate your overall experience at Prince William OB-GYN?
Comments About Your Overall Experience
If you have any suggestions that could help us provide better care, please write your suggestions below.
ONLY COMPLETE THE FOLLOWING INFORMATION IF YOU WISH TO BE CONTACTED ABOUT YOUR COMMENTS ON THIS SURVEY
Do you wish to be contacted by the office Administrator?
If you selected No, thank you for participating in our survey. If you selected Yes, please complete the following information and Thank YOU for your time.
Name
Phone Number
Best Time for the office Administrator to Call You

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