Patient Survey
 
(*) represents a required field. 5) *Name of primary physician you visited today at our clinic.
1) First Name
2) Last Name
3) Phone Number
4) Email
5b) Name of second physician you visited today at our clinic.
 

6) *In what county do you live? Other
7) Did another physician refer you to Graves-Gilbert Clinic? YES NO
7b)   If yes, physician’s name
7c)   If no, how did you hear about Graves-Gilbert Clinic? Check all that apply
 
Family Member Friend Newspaper Ad
Radio Ad TV Ad Health Fair
Community Greeters Yellow Pages Other

8) If you visited the main GGC building, please rate your contact with our Greeters at the front door.
  Excellent Good Fair Poor N/A
9) If you called into GGC, please rate the telephone skills of our staff.
  Excellent Good Fair Poor N/A
10) Please rate your contact with our Receptionist/Registration staff.
  Excellent Good Fair Poor N/A
11) Once checked in at the reception desk, please rate the time you waited to see the physician.
  Excellent Good Fair Poor N/A
12) Once into the office, please rate the personal manner (courtesy, respect, sensitivity, friendliness) of the physician’s staff.
  Excellent Good Fair Poor N/A
13) Rate the personal manner (courtesy, respect, sensitivity, friendliness) of the physician.
  Excellent Good Fair Poor N/A
14) Rate the clinical skills (thoroughness, carefulness, competence) of the physician’s staff.
  Excellent Good Fair Poor N/A
15) Rate the clinical skills (thoroughness, carefulness, competence) of the physician.
  Excellent Good Fair Poor N/A
16) Please rate the time the physician spent with you during your visit.
  Excellent Good Fair Poor N/A
17) Please rate the explanations of any medicine, surgical procedures, tests or your overall medical condition that you received during your visit.
  Excellent Good Fair Poor N/A
18) Please rate your overall understanding of GGC’s billing and insurance procedures as explained by our staff.
  Excellent Good Fair Poor N/A
19) Please rate the comfort and cleanliness of our facility.
  Excellent Good Fair Poor N/A
20) Please rate your overall experience at GGC.
  Excellent Good Fair Poor N/A
21) * Would you recommend Graves-Gilbert clinic to others?
  YES NO
22) Additional Comments
 
23) Would you like to be contacted by a GGC Administrator concerning this survey?  Yes No
(If so, be sure to give your contact information at the top of the page.)