South Riding Family Medicine Contact Us
. Home . . Registration & Forms . . Service Requests . . Insurance & Billing . . Health Resources . . About Us .
*
Service Requests
* Schedule an Appointment
* Prescription Refill Request
* Specialist Referral Request
* Office Visit Survey
* Update Personal Information
* Ask a Nurse/ Provider

Short-cut to:
* Billing Questions
* Bill Payment
* Downloadable Forms
* Contact Us

Office Visit Survey

Please take the time to fill out this survey. All information will be kept confidential, and will only be used to improve our customer service. Thank you for all your comments and suggestions!

Scheduling
  1. Were you able to schedule an appointment that was convenient for you?
Yes
No
  1. Was our staff courteous and helpful?
Yes
No

Registration
  1. Were you satisfied with courtesy and efficiency of the receptionist?
Very Satisfied
Satisfied
Unsatisfied
  1. Were you satisfied with the comfort of the waiting room?
Very Satisfied
Satisfied
Unsatisfied
  1. How long did you wait in the waiting room past your scheduled appointment time before being roomed?
No Wait
Minutes:

Your Visit
  1. Nurses sensitivity and ability to communicate
Very Satisfied
Satisfied
Unsatisfied
  1. The comfort and appearance of the exam room
Very Satisfied
Satisfied
Unsatisfied
  1. The provider's (nurse practitioner or doctor) sensitivity and ability to communicate
Very Satisfied
Satisfied
Unsatisfied
  1. Your overall satisfaction with your care
Very Satisfied
Satisfied
Unsatisfied
  1. Your overall satisfaction with your visit
Very Satisfied
Satisfied
Unsatisfied
  1. How long did you wait in the room before you saw our provider?
No Wait
Minutes:
  1. Would you recommend South Riding Family Medicine to a friend or family?
Yes
No

Our Phone System
  1. Was the line busy?
Yes
No
  1. When you called our office, was the receptionist helpful and friendly?
Yes
No
  1. Was the message in the phone system easy to understand and were the choices clear?
Yes
No
N/A
  1. Were the mailboxes to leave messages for prescription refill, call back and messages to providers available 24 hr/day helpful?
Yes
No
N/A
  1. How long did it take to receive a call back for non-urgent messages?

Website
  1. How satisfied are you with our website?
Very Satisfied
Satisfied
Unsatisfied
  1. Was it easy to use?
Yes
No
  1. How long did we take to respond to prescription refill requests?
  1. How long did we take to respond to appointments requests?
  1. How long did we take to respond to referrals?
Any additional suggestions, or comments

Provider seen (doctor or nurse practitioner)
If you would like our office manager, Pat Rogers, to contact you about your visit, please give us your name, and contact information. We cannot contact you otherwise, as the survey is sent in a secure manner and we cannot retrieve your email address.
Your Name
 Your E-mail
Your Daytime Phone Number
--

 
   
Home  |  Página inicial en Español  |  Contact Us Contact by Phone or E-mail
SOUTH RIDING FAMILY MEDICINE
Lafayette One Business Center
4080 Lafayette Center Drive, Suite 170, Chantilly, VA20151-1218 (directions)  |  Tel: 703-766-5040 Fax:703-766-5047
Legal Disclaimer and Privacy Policy  |  HIPPA Notice of Patient Privacy Practices
Copyright ©2005 South Riding Family Medicine. All rights reserved.