Rate Your Visit

Cholla Medical Group-Primary Care: Patient Satisfaction Survey

We value you as a patient and with each visit we strive to provide exceptional service. We ask you to take a moment to complete this questionnaire. Your input is sincerely appreciated and will be used to help improve our services.

Demographic Information

Gender

MaleFemale

Age

18-2425-3435-4445-5455-6465-7475-8485+

Race

WhiteHispanic/LatinAfrican AmericanOther

Marital Status

SingleMarriedWidowed

Employment Status

EmployedSelf-EmployedUnemployedRetired

Insurance Type

MedicareMedicaidUninsured

Full Time AZ Resident

YesNo

Please let us know how well you think we are doing in the following areas

1) Ease of getting care

Comments regarding Ease of Getting Care?

2) Waiting

Comments regarding Waiting?

3) Front Office (Receptionists)

Comments regarding Front Office?

4) Medical Assistants

Comments regarding Medical Assistants?

5) Billing Staff

Comments regarding Billing Staff?

6) Your Primary Care Physician

Please select your primary care physician:

Comments regarding Your Primary Care Physician?

7) Provider You Saw Most Recently

We realize you may see someone other than your primary care physician in this office.

Who did you most recently visit?

Comments regarding Your Primary Care Physician?

8) Follow-Up Care

Comments regarding Follow-Up Care?

9) Office Environment

Comments regarding Office Environment?

10) Would you refer us to friends and family?

	Great	Good	OK	Fair	Poor	N/A
The likelihood of referring your friends and relatives to us:	Great	Good	OK	Fair	Poor	N/A

Comments regarding Your Primary Care Physician?

Please answer the following questions:

11) Approximately how long have you been a patient with this practice?

Less than 6 monthsAt least 6 months but less than 1 yearAt least 1 year but less than 3 yearsAt least 3 years but less than 5 years5 years or more

12) If you are no longer a patient in our practice, why did you leave?

LocationPhysicianOfficeStaffThis question does not apply to meOther

13) How did you hear about our practice?

Friend or family memberAnother physician/specialistHealth plan/insurance company or associated directoryOnlineOther

14) If your primary care physician is not available, do you:

See a Nurse Practitioner in our officeSee another physician in our officeWait until my primary care physician is availableSee another provider in a different officeGo to an urgent careOther

Cholla Medical Group

Call Us Today: (480) 418-7246

Rate Your Visit

Cholla Medical Group-Primary Care: Patient Satisfaction Survey

Demographic Information

Gender

Age

Race

Marital Status

Employment Status

Insurance Type

Full Time AZ Resident

Please let us know how well you think we are doing in the following areas

1) Ease of getting care

Comments regarding Ease of Getting Care?

2) Waiting

Comments regarding Waiting?

3) Front Office (Receptionists)

Comments regarding Front Office?

4) Medical Assistants

Comments regarding Medical Assistants?

5) Billing Staff

Comments regarding Billing Staff?

6) Your Primary Care Physician

Comments regarding Your Primary Care Physician?

7) Provider You Saw Most Recently

Comments regarding Your Primary Care Physician?

8) Follow-Up Care

Comments regarding Follow-Up Care?

9) Office Environment

Comments regarding Office Environment?

10) Would you refer us to friends and family?

Comments regarding Your Primary Care Physician?

Please answer the following questions:

11) Approximately how long have you been a patient with this practice?

12) If you are no longer a patient in our practice, why did you leave?

13) How did you hear about our practice?

14) If your primary care physician is not available, do you:

Please answer the following questions about the survey

15) Were the survey questions easy to understand?

16) Was the survey easy to complete?

12) Approximately how long did it take to finish this survey?

Additional Comments