Medent Document - Family Medicine Associates of Ithaca

Family Medicine Associates of Ithaca
Tell us what you think
Email: contacts@fma-ithaca.com
Website: www.fma-ithaca.com
Dear Patient,
Please check all answers that apply.
1. How were you referred to our practice?
ο
ο
ο
ο
ο
ο
Would you take a few minutes of your time to help us? We would like to
know how you feel about the care we provide at Family Medicine. We would like to
know how you feel about our medical services, patient-handling systems, physicians,
and staff members.
Please return your completed survey as quickly as possible. For your convenience, we have a survey return box in our waiting area, or you may mail your survey
to us by simply folding it so that our return address shows on the back. Your comments
will help us evaluate our services to ensure that we are truly responsive to your needs.
4. To what extent does our practice meet your needs?
Friend/family member
Physician referral
Yellow pages
Employer medical plan
Saw advertising for Family Medicine. Where?__________________
From our website
2. What was it about Family Medicine that attracted you?
Reputation for quality medical care
Convenient location
Convenient evening hours
Convenient weekend hours
Easy to get an appointment
Meets almost all my needs
Meets most of my needs
Meets only a few of my needs
None of my needs have been met
5. Overall, how satisfied are you with our service?
ο
ο
ο
ο
Other_________________________
ο
ο
ο
ο
ο
ο
ο
ο
ο
Very satisfied
Mostly satisfied
Mildly dissatisfied
Quite dissatisfied
6. Will you come back here again for your medical care?
ο
ο
Yes
No
7. Would you recommend our practice to a family member or
friend?
Other_________________________
3. How satisfied were you with the following:
Excellent
Poor
Availability of convenient appointment
1
2
3
4
Waiting time in reception area
1
2
3
4
Waiting time in exam room
1
2
3
4
Telephone calls handled courteously
1
2
3
4
Telephone calls handled promptly
1
2
3
4
Receptionists friendly and courteous
1
2
3
4
Nurses sympathetic and concerned
1
2
3
4
Billing people helpful
1
2
3
4
ο
ο
Yes
No
8. Which physician or caregiver do you normally see?
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
Dr. Baker
Dr. Breiman
Dr. Darlow
Dr. LaFace
Dr. Midura
Dr. Shallish
Dr. von Felten
Tina Hilsdorf, NP-C
Debra LaVigne, NP-C
Judy Scherer, FNP
9. Who did you see most recently?
Your doctor or nurse practitioner:
Was on time for your appointment
1
2
3
4
Answered your questions
1
2
3
4
Was interested in you
1
2
3
4
Spent enough time with you
1
2
3
4
Returned your calls
1
2
3
4
After-hours answering service
1
2
3
4
Physician responsiveness after hours
1
2
3
4
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
Dr. Baker
Dr. Breiman
Dr. Darlow
Dr. LaFace
Dr. Midura
Dr. Shallish
Dr. von Felten
Tina Hilsdorf, NP-C
Debra LaVigne, NP-C
Judy Scherer, FNP
10. How long have you been a patient of Family Medicine?
ο
ο
12. Other comments about our services:
This was my first visit.
Less than a year
____years
11. Is there a service we should provide that we currently do
not offer?
fold here
Family Medicine Associates
209. W. State Street
Ithaca, NY 14850
fold here