Patient's Name:
Physician's Name: Date:
1.  Was your first contact with our office pleasant and helpful?	Yes No
2.  Were you greeted immediately upon arrival at our office?	Yes No
3. Was the appointment time and office location convenient for you?	Yes No
4. Were you seen and greeted by the nursing staff in a friendly and timely fashion?	Yes No
5. Were your treatment options and procedures explained to your satisfaction?	Yes No
6. Would you refer your friends and family to our practice?	Yes No
7. How did you hear about our Allergic Disease & Asthma Center?
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(For questions #8 & #9, please use the following scale) 1=needs improvement, 2=satisfactory, 3=very good, 4=excellent
8.  How would you rate the warmth and friendliness of your doctor?
9.  How would you rate your overall experience at our practice?
10. Suggestions/comments that would make your experience more pleasant on your return visit?
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