Patient Survey

We want to be sure we are doing everything we can to serve you. Please take a minute to fill out this confidential survey. Just let us know what we are doing well and what we can do better!

Name *

First

Last

Date of Service/Visit *

Phone Number *

Who was your physician/provider during your last visit? *

Email *

Please indicate your level of satisfaction with the following items related to your office appointment. Use a scale of 1 to 5, with 5 being Very Satisfied, and 1 being Not Satisfied.

Please rate the following items related to the delivery of your care. Use a scale 1 to 5, with 5 being very satisfied, and 1 being Poor.

Please indicate the extent to which you agree or disagree with each of the following statements. Use a scale of 1 to 5, with 5 being Strongly Agree, and 1 being Strongly Disagree.

If lab work was done, did you receive your results in a timely manner following your office visit? *

Yes No Not applicable

Would you return to see this physician/provider for further care? *

Yes No Maybe

Would you recommend IFHS to family and friends? *

Yes No Maybe

Did any specific staff member stand out? *

Yes No

Was there any aspect of your care that could be improved? *

Yes No

If yes, who and why? *

If yes, please explain. *

Please tell us what you like best about the care you received. *

Please tell us what you like least about the care you received. *

Do you have any other comment(s) you would like to share with us? *

Patient Survey

Hours

CLINIC Telephone: 907-581-1202