Patient Feedback Form

Patient Feedback Form

Thank you for choosing My Heart Spark P.C.. We are always looking for ways to continue to improve your experience and our service. Please take a few moments to complete this form to provide us with your feedback. Thank you!
Please Provide Your Name If We May Contact You to Improve Our Services For You:

First NameLast Name
Sex
Birth Date

MonthDayYear

Overall satisfaction*

	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
Clinician Knowledge
Clinician Kindness
Clinician Patience
Ease of Scheduling Appointment
Waiting Time
Customer Service

Is this the clinician you usually see if you need a check-up or want advice about your heart health?*

YesNo
For how long have you been going to this clinician?*

Less Than 6 MonthsAt least 6 months but less than 1 yearAt least 1 year but less than 3 yearsAt least 3 year but less than 5 years5 years or moreThis was my first visit with this clinician
Did you contact this clinician's office to get an appointment for heart disease that you already have?*

YesNo
Did you contact this clinician's office to get an appointment to prevent heart disease?*

YesNo
Have you ever been diagnosed with cancer?*

YesNo
Did you contact this clinician's office to get an appointment to learn more about heart healthy habits that can help to prevent ever having cancer for the first time?*

YesNo
Did you contact this clinician's office to get an appointment to learn more about heart healthy habits that can help to prevent cancer from coming back?*

YesNo
When you contacted this clinician's office to get an appointment for care you needed right away, how soon were you able to get an appointment after contact?*

Same dayWithin 24 hoursWithin 48 hoursWithin 3-5 daysAfter 6 days
Did you contact this clinician's office with a medical question during regular office hours?*

YesNoNot applicable
If you contacted this clinician's office during regular office hours, did you get an answer to your medical question that same day?

YesNoNot applicable
Did the clinician explain things in a way that was easy to understand?*

YesNo
Did the clinician seem to listen carefully to you?*

YesNo
Did the clinician seem to know the important information about your medical history?*

YesNo
Did the clinician show respect for what you had to say?*

YesNo
Do you feel the clinician spent enough time with you during your appointment?*

YesNo
Using any number from 0 to 10, where 0 is the worst clinician possible and 10 is the best provider possible, what number would you use to rate this clinician among other clinicians with whom you have had appointments at My Heart Spark P.C.?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Using any number from 0 to 10, where 0 is the worst clinician possible and 10 is the best provider possible, what number would you use to rate this clinician among all clinicians you have ever had appointments with in any organization?*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
In general, how would you rate your overall health?*

ExcellentVery GoodGoodFairPoor
In general, how would you rate your overall mental or emotional health?*

ExcellentVery GoodGoodFairPoor
What is the highest grade or level of school that you have completed?*

8th grade or lessSome high school, but did not graduateHigh school graduate or GEDSome college or 2 year degree4 year college graduateGraduate school degree (such as Master's or PhD) or higher
Are you of Hispanic or Latino origin or descent?*

Yes, Hispanic or LatinoNo, not Hispanic or Latino
What is your race? Mark one or more.*

WhiteBlack or African AmericanAsianNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeOther
How can we improve our service?*

Do we have your permission to share or display your feedback anonymously?*

YesNoPlease check with me about the particular feedback you would like to share
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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RETROSPECTIVE REVIEW CONSENT: I understand that My Heart Spark P.C. (“the Practice”) provides this telehealth visit for me to learn more about protecting my heart. In the future, the Practice may want to look back on all of this work that they have produced to help me. When they look back at everything, they may want to capture summaries of all of the work. These summaries may involve combinations that have my information included in a way that is mixed with everyone else’s and cannot identify me at all. If they look back at this work in this way in the future, they may call this “retrospective research” review. They may present and publish some of the combined and mixed results from this work, in a way that could not identify me. This review would focus on understanding the effectiveness of their services and educational options, so that they can better tailor services/options for the future. Through this review, they may better understand heart health and determine which helpful educational and preventive methods are beneficial in building healthy heart habits. The review committee will understand and respect the privacy of each and every individual. They would present and publish the combined and mixed information from their findings without disclosing my individual personal information in a way that could identify me. By signing below, I consent to my information being used as part of this future review. In the future, I can write them if I ever change my mind and would like my information removed from the combined and mixed results in my research review. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
Signature

Clear

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