Our goal is to make sure you have a positive experience every time you come in contact with our office. We would like you to take a few moments and answer the following questions to help us improve our practice. Please mark the most appropriate box or boxes.

1. Are you a     New patient     Returning patient

2. How did you learn about our office?
	Doctor referral     Insurance referral     Friend
	Other

3. Telephones – What time did you call and how was your experience?

Time of calls: 8:30 – 10:30   10:30 – 12:30   2:00-3:30   After 3:30

How would you describe your ease of reaching our office?
	Phones were busy     I was helped right away
	I was placed on hold for minutes Short period Long period

How was your contact with our staff?
	Great     Average    Below average     Very poor
	Comments:

Did our staff meet your needs?
	Yes    No
	Comments:

4. Appointments
	I was offered appointment times that were convenient for me
	Appointment times were not convenient for me
	Due to: my schedule office schedule
	Comments:

5. Parking
	8:30 – 10:30   10:30 – 12:30   2:00-3:30   After 3:30
	Parking was     Good     Average     Poor
	Comments:

6. Front Desk
	How was your contact with our front office staff?
	Friendly and helpful     Friendly but rushed     Not friendly or helpful
	Comments:

7. Medical Assistants – Back office
	How was your contact with our Medical Assistants?
	Very courteous     Friendly but rushed     Not friendly or helpful
	Were instructions from our staff clear?     Yes     No
	Comments:

8. Physician or Nurse Practitioner
	Who did you see?     Dr Galant     Dr Lin     Susana     Amy
	How was your time with the Physician or Nurse Practitioner?
	Answered every question I asked Seemed more interested in talking than in listening Encouraged me to ask questions I felt it would be imposing to ask more questions
	Were the Doctors or Nurse Practitioners instructions clear?     Yes   No
	Were you satisfied with the treatment you received?     Yes     No
	Comments:

9. Waiting Time
	Did you wait long in our office?     Yes     No
	If yes, where were you waiting? Waiting room Exam room
	How long did you wait?
	Comments:

10. Would you recommend us to friends or relatives based on your experience with us?
	Yes     No
	Comments:

Please right below any additional comments.
Additional Comments: