Online Services: Elizabeth Wende Breast Clinic


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Patient Survey Form

Your comments and suggestions are important to us!

Thank you for coming to the Elizabeth Wende Breast Care LLC.. We are committed to making sure you are satisfied with the care and services you receive at the clinic. Please let us know what you did or did not like about your visit with us, and share any comments or suggestions that would help us to make your next visit here more pleasant.

Printable Version (PDF)

* Denotes required fields.

Date of your appointment: *	MM/DD/YYYY
The scheduled time of your appointment was: *
What type of appointments were you scheduled for? *
Was this your first time at the Elizabeth Wende Breast Care LLC.? *	Yes No
What prompted you to make your appointment with us today? *

Do you agree or disagree with the following statements?

1 - Strongly Agree
2 - Agree
3 - Uncertain
4 - Disagree
5 - Strongly Disagree

	1	2	3	4	5
I was able to make an appointment for a date and time that was reasonable and convenient for me.
The reception and waiting areas were clean and comfortable.
I was encouraged to ask questions and all of my questions were answered to my satisfaction.

The personal manner of the staff in the following areas was courteous, respectful, friendly and sensitive, and my concerns were all addressed.

	1	2	3	4	5
Phone/appointment scheduling
Reception
Technologist
Physician
Person who gave results or assisted the doctor
Office and Billing
Patient Advocate

The professional skill of the staff in the following areas were thorough, careful and competent.

	1	2	3	4	5
Phone/appointment scheduling
Reception
Technologist
Physician
Person who gave results or assisted the doctor
Office and Billing
Patient Advocate

I was satisfied with:

	1	2	3	4	5
the total length of time it took for my appointment.
the time I waited before being brought in to change.
the time I waited before having my mammogram or seeing the technologist.
the time I waited after having my mammogram.

	1	2	3	4	5
I appreciate being able to choose if I want to stay for my results or leave without results if I am in a rush.
I was satisfied with the explanations of test procedures, results and/or treatments that I received from the doctors and technical staff.
I would recommend the Elizabeth Wende Breast Care LLC. to my friends and family.

Additional Comments
Please leave your name, address and phone number (optional).

Would you like us to contact you regarding this survey or any comments you have concerning us?
	Yes No


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