Your name:

Your e-mail:

Date of Appointment:

Time of Appointment:

Physician:

- Select Physician - Albert Johnson, MD James M. Parolie, MD James W. Dwyer, MD Paul P. Vessa, MD Mingi Choi, MD James E. Tovey, MD Richard Chang, MD

1. Appointment available within a reasonable amount of time

2. Appointment scheduled at a convenient time of day

3. Waiting time in the reception area

4. Waiting time in the exam room

4a. How long did you wait from time of check in until you saw the doctor?:

4b. If over 45 minutes, how long did you wait from time of check-in until you saw the doctor and what was your impression as to why?

5. The friendliness and courtesy of our receptionists

6. The caring concern of our nurses

7. The helpfulness of the people in our business office

8. The professionalism of our technical staff

9. Your phone calls answered promptly

10. Availability of medical information/advice by telephone

11. Explanation of your test procedure (if applicable)

12. Your test results reported in a reasonable amount of time

13. Effectiveness of our health information materials

14. The doctor returning your calls in a timely manner

15. The doctor listening to you

16. The doctor taking time to answer your questions

17. The doctor adequately explaining treatment options

18. The thoroughness of the examination

19. Amount of time the doctor spent with you

20. The outcome of treatment prescribed by your doctor

21. Hours of operation convenient for you

22. Overall comfort

23. Adequate parking

24. Signage and directions easy to follow