BCM Patient Satisfaction Survey

BCM Patient Satisfaction Survey

Thank you for taking the time to leave your comments. Your feedback will help us to better serve you.

1) Date of visit:

2) Which BCM facility did you visit?

Baylor Clinic   Baylor Family Medicine (Kirby)   Ophthalmology / The Cullen Eye Institute   Urology   Neurology (Smith Tower)   Neurosurgery   Plastic Surgery / Center for Aesthetic Surgery   Baylor Psychiatric Consultants   Maxine Mesinger Multiple Sclerosis Clinic   Other (please specify)

If you selected other, please specify:

3) Doctor/Department:

4) Survey Questions:

	NA	Poor	Fair	Good	Very Good	Excellent
How would you rate the ease of getting through to the clinic by phone?	How would you rate the ease of getting through to the clinic by phone? NA	How would you rate the ease of getting through to the clinic by phone? Poor	How would you rate the ease of getting through to the clinic by phone? Fair	How would you rate the ease of getting through to the clinic by phone? Good	How would you rate the ease of getting through to the clinic by phone? Very Good	How would you rate the ease of getting through to the clinic by phone? Excellent
Please rate your satisfaction with your appointment date and time.	Please rate your satisfaction with your appointment date and time. NA	Please rate your satisfaction with your appointment date and time. Poor	Please rate your satisfaction with your appointment date and time. Fair	Please rate your satisfaction with your appointment date and time. Good	Please rate your satisfaction with your appointment date and time. Very Good	Please rate your satisfaction with your appointment date and time. Excellent
Please rate the friendliness and courtesy shown to you by our staff.	Please rate the friendliness and courtesy shown to you by our staff. NA	Please rate the friendliness and courtesy shown to you by our staff. Poor	Please rate the friendliness and courtesy shown to you by our staff. Fair	Please rate the friendliness and courtesy shown to you by our staff. Good	Please rate the friendliness and courtesy shown to you by our staff. Very Good	Please rate the friendliness and courtesy shown to you by our staff. Excellent
Please rate the friendliness and courtesy shown to you by our doctors.	Please rate the friendliness and courtesy shown to you by our doctors. NA	Please rate the friendliness and courtesy shown to you by our doctors. Poor	Please rate the friendliness and courtesy shown to you by our doctors. Fair	Please rate the friendliness and courtesy shown to you by our doctors. Good	Please rate the friendliness and courtesy shown to you by our doctors. Very Good	Please rate the friendliness and courtesy shown to you by our doctors. Excellent
Please rate your satisfaction with how promptly you were seen after your scheduled appointment time.	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. NA	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. Poor	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. Fair	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. Good	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. Very Good	Please rate your satisfaction with how promptly you were seen after your scheduled appointment time. Excellent
Overall, how would you rate the quality of care that you received?	Overall, how would you rate the quality of care that you received? NA	Overall, how would you rate the quality of care that you received? Poor	Overall, how would you rate the quality of care that you received? Fair	Overall, how would you rate the quality of care that you received? Good	Overall, how would you rate the quality of care that you received? Very Good	Overall, how would you rate the quality of care that you received? Excellent

5) Please feel free to share with us any comments that will help us continually exceed your expectations!

6) Is there someone you would like to recognize for outstanding service or care?

7) Would you like someone to contact you?

Yes   No

8) If yes, your name:

9) Phone number or e-mail: