86 Baker Avenue Ext.
Suites 300-302
Concord, MA 01742

133 Littleton Road (Route 110)
Emerson Health Center
Suite 205-206
Westford, MA 01886

340 Maple Street
Suite 201
Marlborough, MA 01752

240 South Main Street
Huggins Hospital
Suite K
Wolfeboro, NH 03894

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Patient Survey

Please take a few minutes and tell us how we are doing. We appreciate your valuable time and comments. All your responses will be held confidential!

How did you hear about our practice?

Primary Care Provider
Friend/ Relative
Yellow Pages
Ad in Newspaper
Your Insurance
Other

How much time collectively did you spend waiting in the waiting room and examination room?

5 minutes or less
6-15 minutes
16-30 minutes
31-45 minutes
46 minutes to 1 hour
Over an hour

How much time did the provider spend with you?

Under 15 minutes
Over 15 minutes

How would you rate our clerical staff (check in, check out, appointment coordinator) on:

Getting up to date information on you (insurance, demographics ext. )
	Great Very Good Good	Fair Poor N/A

Friendliness:
	Great Very Good Good	Fair Poor N/A

Patience:
	Great Very Good Good	Fair Poor N/A

Responsiveness:
	Great Very Good Good	Fair Poor N/A

Did our front desk person welcome you when you arrived?

yes no

Did our check out person thank you for coming to our practice during the checkout process?

yes no

What was your overall impression with our billing department (if applicable)?

Who was your office visit with?

Benjamin Solky, MD
Christy Williams, MD
Frank Fechner, MD
Kathleen Joyce, MD
Samuel Goos, MD
Steven Franks, MD

Barbara Bradley, DCNP
Beth McCabe, DCNP
Donna Kulas, DCNP
Kathleen Burke, DCNP
Betty Jo Chiara, Medical Aesthetician
Denise Judson, Medical Aesthetician

Clear Communication:
	Great Very Good Good	Fair Poor N/A

Clinical Knowledge:
	Great Very Good Good	Fair Poor N/A

Patience:
	Great Very Good Good	Fair Poor N/A

Empathy:
	Great Very Good Good	Fair Poor N/A

What office did you visit us at?

Concord, MA
Westford, MA
Marlborough, MA

Can you share with us your overall experience with our practice. Please be as detailed as you can be. We want to know!

What do you consider to be our strengths?

What areas of our medical practice could we improve?

Name:

Phone:

Email Address: