MFM Patient Survey

A. Your Appointment:

Ease of Making Appointment: Excellent Good Fair Poor

Efficiency of the Check-In Process: Excellent Good Fair Poor

Time Spent in the Waiting Room Excellent Good Fair Poor

B. Our Team Members:

Our Friendlieness and Professionalism: Excellent Good Fair Poor

C. Our Communication With You:

Effectiveness of our Communications: Excellent Good Fair Poor

D. Our Facility:

New Room Concept - TV Monitor and Family Participation: Excellent Good Fair Poor

Cleanliness: Excellent Good Fair Poor

Adequate Parking: Excellent Good Fair Poor

E. Your Overall Satisfaction With:

Our Clinic: Excellent Good Fair Poor

Quality of your Medical Care: Excellent Good Fair Poor

Would you recommend LXA to others? Yes No

If you answered no, please explain why.

Is there any way we can improve our services to you?

Is there a staff member you would like to recognize for providing excellent customer service?

Your Name (optional):

Exam Date: