PDQ Care Inc

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Satisfaction Survey

One of the most effective tools available to the Company is patient surveys.If you recently received services from one of our locations, please take the time to tell us about your experience.
Fields marked * are mandatory.

Patient Name*

Date of Birth*

(mm/dd/yyyy)

Telephone Number

Healthcare Provider

Is this your first time to fill out a PDQ Care survey ? Yes No

Please rate the following based on your previous visit(s) to a PDQ Care Clinic.
Scale: (1=poor,3=good,5=excellent)

1. Overall Cleanliness

1 2 3 4 5

2. Hours of operation

1 2 3 4 5

3. Health care providers explaination of

a. Services

1 2 3 4 5

b. Diagnosis

1 2 3 4 5

c. Method of treatment

1 2 3 4 5

4. Health care providers interaction with you

1 2 3 4 5

5. Speed in receiving service

1 2 3 4 5

6. What was your wait time to be seen?

0-15 min 15-30 min 30+ min

7. What was your total time spent in clinic with the health care provider?

0-15 min 15-30 min 30+ min

8. Would you return?	Yes No
9. Do you believe our healthcare provider spent enough time with you?	Yes No
10. Would you recommend our service to others?	Yes No

Additional Comments:

Satisfaction Survey

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