We strive to provide the utmost patient care possible and value your opinion about your experience at our facility.  Please take a moment to complete the following questions.  Your response is confidential.

We are greatful for your time and suggestions.

Name (Optional):
Email Address:
Date of Birth:

Age:
Date of your appointment/
surgical treatment:

 

Your Appointment

Waiting time in the reception area:

 Excellent  Satisfactory  Need Improvement

Waiting time in the exam room:

 Excellent  Satisfactory  Need Improvement

 

Our Staff

Courtesy and friendliness of the front desk:

 Excellent  Satisfactory  Need Improvement

Helpfulness of our staff in making your payment plans:

 Excellent  Satisfactory  Need Improvement

The courtesy and friendliness of the surgical assistants:

 Excellent  Satisfactory  Need Improvement

Were the post-operative instructions adequately explained to you and the person responsible for the your post-operative care?

 Yes  No

 

Your Visit with the Doctor

Which doctor did you see?

 Dr. Ernst  Dr. Pirozzi

Did the doctor take the time to answer your questions:

 Excellent  Satisfactory  Need Improvement

Was the doctor courteous:

 Excellent  Satisfactory  Need Improvement

Did the doctor adequately explain treatment options:

 Excellent  Satisfactory  Need Improvement

Our facility, cleanliness and comfort:

 Excellent  Satisfactory  Need Improvement

Your overall satisfaction with the quality of your medical care:

 Excellent  Satisfactory  Need Improvement

Would you recommend this practice to others?

 Yes  No

If there is any way that we can improve our services to you, please tell us about it:

 

May we contact you regarding your care at our office?

 Yes  No

May we contact you regarding this survey?

 Yes  No

Please provide the best phone number for us to contact you: