North Shore Pain Management
Patient Satisfaction Survey

In an effort to improve your healthcare experience, please take a moment to complete the following survey.

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First Name:
Last Name:
Email Address:
Best Contact Number:
Date of Birth:
Appointment Date:

 
On a scale of 1-5 with five (5) being outstanding and one (1) being the worst, please rate the following questions:

  1 2 3 4 5
Availability of a convenient appointment:
Wait time for an appointment:
Wait time in the waiting room:
Were you taken to see the doctor on time:
Courtesy and friendliness of the person answering the phone:
Courtesy and efficiency of the check-in process:
Courtesy and efficiency of the check-out process:
Courtesy of your physician:
Were all of your questions answered:
Respect for your privacy:
Cleanliness of our facility:
Comfort of our waiting room:
Promptness of a return call when leaving a message:
Overall satisfaction of our clinic:
How likely are you to refer your family and friends to our clinic:
What is your first impression when walking into our clinic:
Are there any improvements you would like to see?
What is the one thing you would like to see changed?
What do you like most about your care here?
What do you like least about your care here?
Additional comments and/or questions:
 
Your Name (optional): Today's Date (optional):