Office of Physician Relations

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Referring Physician Survey Form

Your Name
Your Clinic
  Please rate services (1=Poor, 3=Average, 5=Excellent)

Access

Access
Ease of scheduling your ambulatory patient

Our ability to see referred patients within acceptable amount of time

Helpfulness of staff on phone

Online appointment ease

Ease of access to our physicians for phone consults

Efficiency of patient transfers

Care

Care
Extent to which we met your patients' needs

Extent to which we met your needs/requests

Patient outcomes obtained here

Communication

Communication
Quality of feedback

Timeliness of information received after a clinic visit

Quantity of information

Overall Assesment

Overall Assesment
Quality of our referral process

Overall rating of the care we deliver to your patients

Overall rating of services we deliver to you

Likelihood of you referring patients in the future

Please identify two departments that provide excellent service.
Please identify two departments that need improvement.
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