Desert Mountain OB/GYN, P.C.
14220 Northsight Blvd Ste 150 Scottsdale, AZ 85260/fax (480) 585-0828

Patient Satisfaction Survey

Date of appointment?
Which provider did you see today?
How did you hear about us?
Physician Referral Name of Physician
Existing Patient

PLEASE RATE THE FOLLOWING (Circle the answer that best reflects your experience)

Excellent Very Good Good Fair Poor N/A
Experience of scheduling your appointment
First Impression of our office
Wait time in the lobby
Courtesy and respectfulness of the staff:
      Front Office
      Medical Assistant
      Physician/Nurse Practitioner
Adequate time with the provider
Questions answered thoroughly
Understood the oral/written instructions given
Respectful of your privacy
What was the primary reason for your visit?
Preventative Exam
Problem or illness
Obstetrical Care

Likelihood of recommending our office to others

OPTIONAL: This survey is intended to provide honest feedback and you contact information is not necessary. If you would like a manager to contact you to discuss your experience, please provide us with the following:

Your Name:     Your Phone

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