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How Are We Doing?

Please complete this survey so we may improve the quality of care for our patients. However, please do not sign this fill this out unless you have previously signed a HIPAA release with us and reviewed our Notice of Privacy Practice. Thank you!

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Please provide the following information to help us best serve you.

First Name
Last Name
Email
Phone

1.	Month of Visit:
2.	This is my first visit: Yes No None
3.	I was referred to the practice by: Referring Physician Friend Self Other None If Other, please specify:
Instruction	Please rate the following items:
4.	Ease of making my appointment: Excellent Good Fair Poor n/a None
5.	Appointment available within a reasonable amount of time: Excellent Good Fair Poor n/a None
6.	Ease of check-in and registration process: Excellent Good Fair Poor n/a None
7.	Waiting time in the reception area: Excellent Good Fair Poor n/a None
8.	Waiting time in the exam room: Excellent Good Fair Poor n/a None
9.	Ease of getting a referral: Excellent Good Fair Poor n/a None
10.	The courtesy and respect of the people I spoke with on the phone: Excellent Good Fair Poor n/a None
11.	The courtesy and respect of the nursing staff: Excellent Good Fair Poor n/a None
12.	The courtesy and respect of the care providers (physicians, nurses): Excellent Good Fair Poor n/a None
13.	The courtesy and respect of the sonographers: Excellent Good Fair Poor n/a None
14.	The courtesy and respect of the genetic counselor: Excellent Good Fair Poor n/a None
15.	The helpfulness of the people in the business office: Excellent Good Fair Poor n/a None
16.	My phone calls were answered promptly: Always Occasionally Sometimes Never n/a None
17.	Availability of medical information/advice by telephone: Excellent Good Fair Poor n/a None
18.	Ability to obtain prescriptions by phone: Excellent Good Fair Poor n/a None
19.	Test results reported in a reasonable amount of time: Excellent Good Fair Poor n/a None
20.	Explanations concerning procedures and tests during my pregnancy: Excellent Good Fair Poor n/a None
21.	Ability to contact the office after hours: Excellent Good Fair Poor n/a None
22.	Care provider listened to my questions and concerns: Excellent Good Fair Poor n/a None
23.	Care provider answered my questions: Excellent Good Fair Poor n/a None
24.	Care provider’s instructions relate to my care or treatment: Excellent Good Fair Poor n/a None
25.	Hours of operation: Excellent Good Fair Poor n/a None
26.	Overall comfort of the office/facility: Excellent Good Fair Poor n/a None
27.	Availability of parking: Excellent Good Fair Poor n/a None
28.	Office/facility signs and directions are easy to follow. Excellent Good Fair Poor n/a None
29.	Overall satisfaction with the practice: Excellent Good Fair Poor n/a None
30.	Overall satisfaction with the quality of my medical care: Excellent Good Fair Poor n/a None
31.	I would recommend the practice to others. Yes No None
32.	If no, please explain why.
33.	My office visit included: ultrasound only OB office visit genetic counseling ante partum testing
34.	The provider who cared for me during my visit was:
35.	My age group is: under 18 18-30 31-40 41-50 51-60 None
36.	Please use the space provided below for any additional comments.

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