825 Wehrle Drive
Williamsville, NY 14221
310 Sterling Drive, Suite 100
Orchard Park, NY 14127

Patient Satisfaction Survey

Instructions:
You have recently received care by the practice. We are very interested in how you feel about the care provided.

Name:
Title:
Company Name:
Email:
Address:
City:
State:
Zip:
Phone:
Fax:
Comments:
Please send me more information:

a)   Cut and paste the rest of the form into the "Comments" box above, then reply to the various questions.

                 -or-

b)   Print this page, fill out the survey by hand, and fax it to us at (716) 634-6056

Your comments will be used to provide input in our continuing effort to improve the care that we provide to our patients. Also comment of any positive or negative experiences during your visit.

1. Date of last visit:       _______________
2. Which office: Wehrle (or) Park.       _______________
3. Was this your first visit to the practice?       _______________
4. Patient's age:       _______________ Male (or) Female       _______________
5. Name: (optional)       _______________
6. Phone number:       _______________

Circle or fill in a rating for the following questions:
Scale:   1 - very poor
               2 - poor
               3 - fair
               4 - good
               5 - very good

Scheduling

1. When you spoke with the scheduling person, helpfulness of the person you spoke with.
         1       2       3       4       5       ______
2. If you spoke with someone over the phone, helpfulness of the instructions about office location and parking.
         1       2       3       4       5       ______
3. How easy was it to get an appointment for the date and time you wanted?
         1       2       3       4       5       ______
4. Helpfulness of the person at the front desk?
         1       2       3       4       5       ______
5. How well were billing and insurance questions handled?
         1       2       3       4       5       ______
6. Comments - describe good or bad experiences:

Office Visit / Treadmill / EKG / Cardiolite / treadmill / pacemaker / catheterization /vascular test (carotid Doppler) /Holter / AICD (include those that apply for your last visit, delete those than do not.)

1. Friendliness of the staff in this area.
         1       2       3       4       5       ______
2. Time spent waiting in the office/testing area.
         1       2       3       4       5       ______
3. Friendliness of the physician that worked with you during the exam/test.
         1       2       3       4       5       ______
4. Explanations given to you by this doctor about you test or treatment.
         1       2       3       4       5       ______
5. Explanations given to you by other staff about what was being done to you.
         1       2       3       4       5       ______
6. Technical skill of staff.
         1       2       3       4       5       ______
   Comments - describe good or bad experience:

Billing and Payment

1. How well was your bill handled and explained, if you paid your bill at this appointment?
         1       2       3       4       5       ______
2. If you received your bill through the mail in the past, how understandable was it?
         1       2       3       4       5       ______
3. If you phoned about your bill in the past, how well were your questions answered?
         1       2       3       4       5       ______

Cardiac Rehabilitation

1. Helpfulness of the staff.
         1       2       3       4       5       ______
2. Availability of class time preference.
         1       2       3       4       5       ______
3. Helpfulness of knowledge learned while in rehab program.
         1       2       3       4       5       ______
   Comments: Describe good or bad experience.

General Rating

1. Overall how was your experience with us?
         1       2       3       4       5      ______
2. Would you recommend our practice to other?
         1       2       3       4       5       ______
   Comments:

If you would like to speak to someone about your visit, please contact the office administrator at 634-3243. Thank you for your time and comments.