25500 Meadowbrook Road
Suite 275
Novi, MI 48375
(248) 438-5228

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Established patient

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Date of appointment

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What was the purpose of your visit?

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Which doctor did you see:

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Was there a particular employee who you were impressed with during your visit?

On a Scale of 1-5 with 5 being Excellent, please rate your last visit with us.

(1-Poor 2-Fair 3-good 4-Very Good 5 Excellent)

Did you receive a reminder call prior to your appointment? Yes    No

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Ease of setting your appointment  5    3   2   1

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Greeting by our receptionist when you arrived 5   4   3   2   1

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Cleanliness/neatness of the exam room 5   4   3   2   1

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Cleanliness/neatness of the office 5   4   3   2   1

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Length of time you had to wait before you were called for your appointment 5   4   3   2   1

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Friendliness of our office staff 5   4   3   2   1

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Friendliness of the physician 5   4   3   2   1

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Quality of the service performed 5   4   3   2   1

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Degree to which your concerns were addressed by the physician 5   4   3   2   1

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Degree to which your concerns were addressed by the office staff 5   4   3   2   1

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If you used our website, did you find it efficient and helpful? 5   4   3   2   1

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If you require surgery, did you find the surgical coordination friendly and efficient? 5   4   3   2   1

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The ease of checking out and paying for the appointment 5   4   3   2   1

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In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices and procedures.



How likely is it that you would recommend our office to your family members, co-workers, and friends?
5   4   3   2   1

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Would you like to provide us with your contact information? Yes No
Full Name:
Phone Number:
Email:


Total Score

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