Patient Satisfaction Survey

Your Age:

Your Gender:

Male Female

Is this your first visit to our office?

Yes No

Your appointement date:

Which provider did you see?

Dr. Flax Dr. Dorsch Dr. Herman Dr. Mauk Dr. Thomson Dr. Nguyen Pat Walzel

Do we participate in your insurance?

Yes No

Were you able to make an appointment easily and in a reasonable time period?

Yes No

When you called to make an appointment, was the office staff helpful and courteous?

Yes No

Upon arrival at our office was the front office staff helpful and courteous?

Yes No

If no, please provide your comments here:

The front office staff that made your appointment

The front office staff that assisted you during your appointment

Your overall healthcare at Digestive and Liver Specialists

The thoroughness of your treatment

Explanations of medical procedures and tests

Attention to what you had to say

Friendliness and courtesy shown you by your provider

Friendliness and courtesy shown you by our clinical staff

Amount of time you had with provider(s) and staff during a visit

Friendliness, helpfulness, and courtesy shown you by our billing staff

Referred by another patient

Referred by another doctor

Referred by family member or friend

Telephone listing

Web site

Close to home/business

Other

Could we have done anything to make your visit better in anyway?

Any additional comments you may wish to share with us?

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