Patient Survey

What you think about our services

Pottstown Medical Specialists, Inc. is dedicated to providing quality health care services to you.

Please take a moment and let us know how we are doing.

Thank you for helping us to improve our service.

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Phone

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Name

First Last

Email*

Phone

Which office did you visit?

Select a Choice

First Choice

Second Choice

Third Choice

Which provider did you see?

How many miles did you travel to get to our office?

Under 1 Mile

1 to 3 Miles

3 to 5 Miles

5 to 10 Miles

over 10 Miles

Which of the following influenced your decision to use our office? (check all that apply)

Referred by another patient

Referred by a doctor

Referred by a friend or family member

Physician Referral Service

Doctor participates in your HMO

Telephone listing

Close to home or office

Other

Please let us know who referred you

What health insurance do you have?

Medicare

Medicaid

Blue Cross/Blue Shield

Aetna/US Healthcare

Cigna

Keystone

Personal Choice

Other

How long did you wait to be seen by the physician?

Under 15 minutes

15 to 30 minutes

30 to 45 minutes

45 minutes to an hour

Over 1 hour

Please rate us

	Excellent/Good	Average	Below Average/Poor	N/A
Courtesy and helpfulness of receptionist when you called to make your appointment
Ability to get a timely appointment
Office location
Parking availability
Courtesy and knowledge of staff
Receptionist
Phone Nurse
Schedulers
Billing
Floor Nurse
Medical Records
Courtesy of provider
Provider's patience and interest in your problem
Time our professional spent with you
Provider's explanation and treatment
General quality of medical care you received

Additional Comments