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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 Town Center 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?

Provider seen (doctor or nurse practitioner)
Please fill out contact information so we can contact you. We have no way to contact you unless you fill this section. Thank you for helping us provide you with better service at Town Center!
Your Name
 Your E-mail
Your Daytime Phone Number
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Any additional suggestions, or comments
   
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TOWN CENTER FAMILY MEDICINE
12110 Sunset Hills Road, Suite LL20, Reston, VA 20190 (directions)  |  Tel: 703-834-1473  |  Fax: 703-318-7463
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