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Patient feedback form




Please rank from 1 - 10 ( ten being excellent service, one being terrible:)

1. Your experience with our office making your appointment. (from 1 - 10 )

was the receptionist friendly, knowledgable, able to answer all your questions?

2. How did you get referred to our office ?

 referred by your doctor

 referred by a friend or previous patient of ours may we ask who - to send outr thanks

 heard radio advertising in english

 heard radio advertising in spanish

 heard radio advertising in polish

 TV advertising

 other : please explain

3. How was your interaction with the receptionists at our office? (from 1 - 10 )

4. Any problems in the reception area?

5. Waiting time was : (from 1 - 10 )

 less than I expected

 about what I expected

 much more than I expected

6. Your impressions of our office: (from 1 - 10 )

7. Your interaction with Dr Feinstein: (from 1 - 10 )

8. Diagnostic testing procedures for your problem: (from 1 - 10 )

9. Summary Session with Dr Feinstein after the diagnostic procedure?

10. OVERALL - how would you rate your experience with Dr Feinstein and his

staff for the evaluation and diagnosis of your problem?

11. Would you recommend our office and our Dr and staff to your family and friends?

12. Do you have any suggestions and / or recommendations about our services

that would improve our care?