Your Name:   Patient Name:   

Your Email Address: 

Is this review pertaining to a particular day? (please provide date)   

(Please fill in the blanks and check the appropriate boxes below that pertain to your experience)

Please rate your experience with our receptionists:

A. Receptionist name: 

    Calls answered in a courteous and helpful manner

    Request handled professionally

    Length of wait time in waiting room reasonable

    Receptionist who greets you is helpful and friendly

    (Please feel free to add additonal comments)

Please rate your experience with the nurse/medical assistant:

B. Nurse/Medical Assistant name: 

    Person escorting you to the exam room was courteous and helpful

    The length of time you wait in the exam room is reasonable

    The nurse/medical assistant answered your questions and concerns in a clear and understandable manner

    The nurse/medical assistant treated you/your family member in a caring, respectful manner

    (Please feel free to add additional comments)

Please rate your experience with your provider:     

C. Provider/Nurse Practitioner name: 

    You are satisfied with the quality of care you received

    Provider listened to your questions and concerns

    Provider appropriately assessed your medical condition

    Provider answered all your questions and concerns in a clear and understandable manner

    Provider treated you in a caring, respectful, professional manner

    Provider explained exam findings, tests ordered, diagnosis, medications/plan of care in a clear and understandable manner

    Provider made you feel comfortable to ask questions about your health

    Provider gave you advice on what to do if symptoms persist or worsen

    Provider explained when and how to follow up

    (Please feel free to add additional comment):

Please rate your experience with our billing staff:

D. Billing Staff name: 

    Bills you receive are easy to understand

    Billing staff handles your questions in a courteous and helpful manner

    (Please feel free to add additional comments)

D. Please answer the following question on your overall experience:

    I would recommend Duson Family Healthcare to a friend or relative

    I would NOT recommend Duson Family Healthcare to a friend or relative

    (Please feel free to add additional comments)