Date of last visit:      Was this your first visit: Yes No

Please select the provider you saw on this visit:

When contacting the office, the phone staff was pleasant.

It was easy to schedule a convenient appointment

I was able to schedule an appointment within a reasonable amount of time.

The information I received prior to my visit was helpful.

If you had surgery, was the surgery scheduling process convenient, clear and informative?

Comments and Suggestions:

I was greeted and registered promptly.

The Registration staff was courteous and helpful.

The forms I was asked to complete were easy to understand.

My wait time was reasonable.

Comments and Suggestions:

The office is in a convenient location.

The parking area is convenient.

The waiting area is comfortable.

The office decor is attractive and cheerful.

I was satisfied with the quality of food at the café.

The café was clean.

The café staff was courteous and helpful.

Comments and Suggestions:

The nurse gave me her complete attention.

The nurse was courteous and friendly.

The nurse was able to answer my questions and provide assurance.

I was satisfied overall with my nursing care.

If I required a return telephone call from the nurse, my call was returned in a reasonable amount of time.

Comments and Suggestions:

My wait time in the exam room was reasonable.

My provider gave me his complete attention.

My provider answered my questions clearly.

My provider explained my treatment options thoroughly.

My provider was courteous and friendly.

Comments and Suggestions:

I was satisfied with the care I received from the x-ray staff

I was satisfied with the care I received from the MRI Staff.

I was satisfied with the care I received from the cast room staff

I was satisfied with the care I received from the Physical Therapy Staff.

I was satisfied with the procedures for scheduling appointments with the MRI and Physical Therapy Departments.

I was satisfied with scheduling follow-up appointments with my provider.

I was satisfied with the check-out process.

Comments and Suggestions:

The staff obtained any authorizations or pre-certifications necessary.

The billing staff was courteous.

All my insurance questions were answered so that I clearly understood my coverage.

My billing statements are easy to understand.

Comments and Suggestions:

The staff maintained my personal privacy during my visit (changing area gown, etc.)

The staff maintained the privacy of my medical information.

Comments and Suggestions:

Overall, I am very confident in the care I received from Sierra Pacific & Orthopaedic and Spine Center.

I will recommend Sierra Pacific Orthopaedic and Spine Center to my friends and family.

Your gender Male Female

Please select you age in years at your last birthday from the age groups below:

Under 16      16-24      25-34      35-44      45-54      55-64      65 and Over

Did the patient complete this form? Yes No

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