Patient Survey

Please help us to care for you by providing feedback about your experience with our office and staff.

Please note this survey is not related to your surgical treatment. This feedback will assist to continually monitor and change our system to serve you better.

We thank you for your time.

Physician Name:

Which site did you visit?

How would you rate the following?

Was this your first visit to BrizBrain & Spine?
 Yes No
Ease in getting through to us by phone
 Excellent Very good Good Fair Poor Does not apply
Courtesy of staff taking your call
 Excellent Very good Good Fair Poor Does not apply
Time between making the appointment and visit date
 Excellent Very good Good Fair Poor Does not apply
The waiting room and amenities were clean and presented well
 Excellent Very good Good Fair Poor Does not apply
Waiting time to see the doctor
 Less than 15 minutes 15-30 minutes 30 to 45 minutes 45 minutes to 1 hour More than 1 hour
Doctor’s personal manner (courtesy, respect, sensitivity)
 Excellent Very good Good Fair Poor Does not apply
Doctor’s instruction regarding care and treatment
 Excellent Very good Good Fair Poor Does not apply
Enough time and comfort to ask questions
 Excellent Very good Good Fair Poor Does not apply
Likelihood that you would recommend us to a friend or relative
 Likely Unlikely
Did you visit the website to gain further information?
 Yes No
If Yes, before or after consultation?
 Before After
Comments
Email address for further correspondence:

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