Garrett Surgical Group, P.A.



            Please fill out the questionnaire form below to help us serve you better.

 

    Name :
    Address :
    City, State and Zip :
    Home Phone Number :

    Please Select only one per question
    Excellent   Good  Fair  Poor  No Contact
    Our Phone Service:                               
    Ease of scheduling your office visit:                               
    Your interaction with the front desk personnel:                               
    The appearance, lay out of our office:                               
    Your interaction with the Clinical assistants:                               
    Your experience with a surgical procedure performed in the office:                               
    Coordination between the hospital and our office for scheduling a surgical procedure:

                                  

    Coordination between our office and the office of your Family/Primary care physician:                               
    The courtesy and helpfulness of our office staff:                               
    Your interaction with our billing department:

                                    

    Your overall experience at our office.

                                  



    Agree        Disagree          Not Applicable
    Surgeon was on time for my visit(s).                                        
    His appearance was professional.                                        
    He spent adequate time with me.                                        
    He performed an adequate physical examination.                                        
    He spent enough time answering my questions.                                        
    His bedside manner in the hospital was good.                                        
    I received sufficient instructions from my Surgeon after surgery.                                        
    I am pleased with the outcome of my surgery.                                        
    I am pleased with my Surgeon.                                        
    I would want the same Surgeon to operate on me again, if necessary.                                        
    I recommend my Surgeon to others.                                        
       
    Comments :


 
Copyright ©2000 I.C. Electronics ICEWEB.NET; Page Design by ICEWEB.NET