Mid-Delta Health Center Patient Satisfaction Survey

Mid-Delta Health Center Patient Satisfaction Survey

Please fill out this survey regarding your visit today. We appreciate you taking the time to help us improve your patient experience.
Date of Appointment

MonthDayYear
Date
Age of Patient
Please choose your provider

Dr. SchalchlinDr. PattenDr. KellyDr. TracyDr. WilsonDr. HopkinsonHaley Ligon, APRNAshley Loftis, PANancy Hornsby, APRNTiffany McPherson, LCSWBlair Keller, APRNLori Wilson, LACLauren Moore, APRN
On a scale of 1 – 5, 1 being very poor and 5 being very good, how would you rate each of the following:
Ease of making appointment by phone:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Ease of getting care and ability to be seen:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Hours of operation are reasonable:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Reasonable waiting time:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Coordinating your care to the proper specialists and/or resources needed in adequate time:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Provider’s ability to listen to what you say and to feel like you are a part of your healthcare decision:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Getting a question answered during and after clinic hours:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
How do you rate the following?
Behavioral Health Services:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Nurses/Dental Assistants:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Lab/X-Ray Technician:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Front Desk Staff:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Neat and clean building:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Fees for services reasonable and affordable:

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Information provided to you in a way that is understandable: (printed materials, interpretation service, etc.)

1

2

3

4

5

1 is Very Poor, 5 is Very Good
Do you consider MDHS your regular source of care?

YesNo
Addition Comments
Optional: Contact Details
Your Name

First NameLast Name
E-mail
example@example.com
Phone Number
Should be Empty:

Mid-Delta Health Center Patient Satisfaction Survey

How do you rate the following?

Optional: Contact Details