Dr. Max Garoutte
Metro North Cardiovascular Associates, PA
Patient Satisfaction Survey
   
Patient Name:
   
Referring Physician
   
Reason For Visit:
   
 
1
2
3
4
5
6
Excellent
Good
Acceptable
Fair
Poor
N/A
   
1. Hours when the doctor's office is open.
2
3
4
5
6
   
2. Convenience of location of doctor's office.
2
3
4
5
6
   
3. Length of time you waited between making an appointment and the day of your visit.
2
3
4
5
6
   
4. Length of time spent waiting at office to see the doctor.                                          
2
3
4
5
6
   
How many minutes did you wait?    _______ minutes
   
5. Cleanliness of the doctor's office.
2
3
4
5
6
   
 
1
2
3
4
5
6
Excellent
Good
Acceptable
Fair
Poor
N/A
   
6. Friendliness and courtesy shown to you and by the staff.
2
3
4
5
6
   
7. Friendliness and courtesy shown to you and by the doctor.
2
3
4
5
6
   
8. Personal interest in you and your medical problems shown by your doctor. 
2
3
4
5
6
   
9. Explanation given to you about medical tests, procedures, and treatment plans
2
3
4
5
6
   
10. Amount of time you have with the doctor during a visit.
2
3
4
5
6
   
 
1
2
3
4
5
6
Excellent
Good
Acceptable
Fair
Poor
N/A
   
11. Compared with your experience with other physicians, how would you compare Dr. Garoutte?
2
3
4
5
6
   
12. Would you recommend the doctor to a friend?
2
3
4
5
6
   
Comments:
   
Patient Signature:
Print Name:
Date of Survey:
 

 
© Copyright 2009. All rights reserved.