Referring Physician Survey Form

Your Name	*
Your Clinic	*
	Please rate services (1=Poor, 3=Average, 5=Excellent)
Access
Ease of scheduling your ambulatory patient	1 2 3 4 5
Our ability to see referred patients within acceptable amount of time	1 2 3 4 5
Helpfulness of staff on phone	1 2 3 4 5
Online appointment ease	1 2 3 4 5
Ease of access to our physicians for phone consults	1 2 3 4 5
Efficiency of patient transfers	1 2 3 4 5
Care
Extent to which we met your patients' needs	1 2 3 4 5
Extent to which we met your needs/requests	1 2 3 4 5
Patient outcomes obtained here	1 2 3 4 5
Communication
Quality of feedback	1 2 3 4 5
Timeliness of information received after a clinic visit	1 2 3 4 5
Quantity of information	1 2 3 4 5
Overall Assesment
Quality of our referral process	1 2 3 4 5
Overall rating of the care we deliver to your patients	1 2 3 4 5
Overall rating of services we deliver to you	1 2 3 4 5
Likelihood of you referring patients in the future	1 2 3 4 5
Please identify two departments that provide excellent service.
Please identify two departments that need improvement.
Comments