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Patient Satisfaction Survey:

1. Name: (optional)
Email address:

2. Age:

0-20

21-40

41-60

61++

3. Male Female

4. Insurance: (Blue Cross & Blue Shield, Kaiser, CIGNA, Workcomp, etc.)

5. Which SPA member did you visit?		6. Which physician did you see?
Carondelet Orthopaedic Surgeons, P. C.
Drisko, Fee & Parkins
Johnson County Orthopedics
Kansas City Bone and Joint Clinic
Orthopaedic Professional Association
Rockhill Orthopaedics

7. What was the purpose of your visit?

Initial Visit (consult)

Second Opinion

Emergency

Follow-up/Post-operation

Based on your experience and feelings,
please rate questions 8 through 30. Check
the number that best expresses your reaction.

Extremely Satisfied
Very Satisfied
Satisfied
Somewhat Dissatisfied
Very Dissatisfied

  N/A   Not applicable 8. Convenience of the location of the office?
   1 2 3 4 5 N/A

9. How long you waited to get an appointment?
   1 2 3 4 5 N/A

10. [If you telephoned for an appointment:] Getting through to the office by phone?
   1 2 3 4 5 N/A

11. [If you telephoned for an appointment:] Was your call answered courteously?
   1 2 3 4 5 N/A

12. Were you advised of any information (x-ray, referral form, etc.) or need for early arrival?
   1 2 3 4 5 N/A

13. Where office policies regarding payment and insurance requirements communicated to you in a clear and courteous manner?
   1 2 3 4 5 N/A

14. Were you greeted with friendliness and prompt assistance at reception?
   1 2 3 4 5 N/A

15. Did you find our office clean and pleasant?
   1 2 3 4 5 N/A

16. If you called our office after hours or on a holiday, did the answering service answer the telephone promptly and courteously?
   1 2 3 4 5 N/A

17. If you requested a call back from the physician, did you receive it promptly?
   1 2 3 4 5 N/A

18. Satisfaction with length of time spent waiting at office to see the physician?
   1 2 3 4 5 N/A

19. The office staff was friendly courteous and helpful?
   1 2 3 4 5 N/A

20. Office staff was sensitive to my needs?
   1 2 3 4 5 N/A

21. Was the staff professional?
   1 2 3 4 5 N/A

22. Office staff answered my question completely and to my understanding?
   1 2 3 4 5 N/A

23. Did the physician explain any medical procedures or tests?
   1 2 3 4 5 N/A

24. The technical skills (thoroughness, carefulness, competence) of the physician?
   1 2 3 4 5 N/A

25. Physician attention to what you have to say?
   1 2 3 4 5 N/A

26. The personal manner (courtesy, respect, sensitivity, friendliness) of the physician?
   1 2 3 4 5 N/A

27. Time spent with the physician you saw?
   1 2 3 4 5 N/A

28. What is the likelihood that you would recommend this physician to family and friends?
   1 2 3 4 5 N/A

29. The visit overall?
   1 2 3 4 5 N/A

30. Did you have an excessive wait for any of our services? If so, which service?

31. How might the service of our practice be improved?

32. Your comments on parking, grounds, buildings, etc.?

33. What information did you find most helpful on the SPA Web site?

34. What information or services would you like to see added to the SPA Web site?

Any Additional Comments?

Would you like someone to respond?
Yes No
Daytime phone number:
Evening phone number:
Time when convenient to call:

Thank you again for your time!

All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. Specialty Physicians Alliance disclaims the creation of a physician/patient relationship and responsibility for any and all liability for injury and/or other damages which result from an individual using the materials provided on the Internet. Use of this online service is subject to the attached disclaimer.