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1. The person who answered the telephone was:
(Check one or more that apply)

Extremely helpful
Helpful
Rude
Acted as if my call interrupted them
Seemed rushed
Noticeably unfriendly

2. Upon entering the practice I was:
(Check one or more that apply)

Genuinely and warmly greeted by name
Acknowledged by name
Acknowledged but not by name
Ignored

3. When arriving for my visit I was:
(Check one or more that apply)

Seen by the doctor at my appointed time
Left waiting for less than 10 minutes
Left waiting for less than 20 minutes
Left waiting for more than 20 minutes

4. The doctor’s assistant’s were:
(yes or no)

Yes No - Friendly and supportive
Yes No - Confident in their tasks
No Yes - Preoccupied or distracted
No Yes - Rushed

5. During my time with the doctor he was:
(yes or no)

Yes No - Friendly
Yes No - Confident
No Yes - Rushed
Yes No - Focused
No Yes - Preoccupied

6. When the doctor explained treatment:
(yes or no)

Yes No - All my questions were answered
Yes No - I understood exactly what the doctor had recommended
No Yes - I was overwhelmed by the amount of treatment recommended
Yes No - I was welcomed to go at my own pace
Yes No - My questions about price and alternative treatments were answered

7. When scheduling my next appointment:

I was offered appointment times that fit my schedule
Finding a convenient appointment time was a challenge
I had to settle for inconvenient appointment times

8. The financial arrangements offered by the practice:

Were flexible and fit my needs
Failed to provide enough options
Were patiently explained to me by a staff member who worked hard to help me fit this treatment into my budget

9. I would recommend this practice to my friends:

Without reservation
With some misgivings
Not at all
I would go out of my way to warn others about this practice