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Bennett S. Romanoff, MD
Chief of Ophthalmology
Flower Hospital
Flower Hospital Medical Office Building
5300 Harroun Road Ste 112
Sylvania, OH 43560
419-885-5556
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Patient Satisfaction Survey
Please invest a few moments to rate our people and procedures. This feedback enables us to continue to improve.
There are 13 questions like the one below, several of which may not apply to you.
Patient Survey
id
date time
1. When you called for an appointment, were you satisfied with the response from the person who answered the telephone?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 2
2. When you arrived at the office, did you find the receptionist to be:
Friendly and courteous?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Helpful?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 3
3. How acceptable was the amount of time spent in the reception area and examining room, before seeing the doctor?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 4
4. When you were called to the examining room, did you find our nurse/technician to be:
Friendly and courteous?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Helpful?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Sympathetic and caring?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 5
5. During your examination, did you find the doctor to be:
Friendly and courteous?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Helpful?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Sympathetic and caring?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 6
6. When you saw the doctor, were you satisfied that he/she spent an appropriate amount of time with you, answered your questions, and explained medical procedures and treatments to your satisfaction?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 7
7. How satisfied were you with the doctor's diagnosis and treatment recommendations?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 8
8. If surgery was recommended, how satisfied were you with the information provided by the doctor/nurse regarding the need for the surgery and the detail provided about the recommended procedure(s)?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Survey Page 9
9. If you had surgery, how satisfied were you with your post-operative follow-up care?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Survey Page 10
10. When asking billing/insurance questions, did you find our billing/insurance staff to be:
Friendly and courteous?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Helpful?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Survey Page 11
11. Please rate your overall experience with our practice:
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 12
12. Would you recommend our practice to your friends?
No
Maybe
Yes
Survey Page 13
13. Please provide any additional comments.
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