Survey New patient Established patient Required Date of appointment Required What was the purpose of your visit? ------------------ Hip or Knee Joint Replacement Shoulder/Elbow Wrist or Hand Trauma & Fractions Referral Other Required Which doctor did you see: ------------------ Germaine R. Fritz, D.O. David W. Prieskorn, D.O. Unsure Required Was there a particular employee who you were impressed with during your visit? On a Scale of 1-5 with 5 being Excellent, please rate your last visit with us. (1-Poor 2-Fair 3-good 4-Very Good 5 Excellent) Did you receive a reminder call prior to your appointment? Yes No Required Ease of setting your appointment 5 4 3 2 1 Required Greeting by our receptionist when you arrived 5 4 3 2 1 Required Cleanliness/neatness of the exam room 5 4 3 2 1 Required Cleanliness/neatness of the office 5 4 3 2 1 Required Length of time you had to wait before you were called for your appointment 5 4 3 2 1 Required Friendliness of our office staff 5 4 3 2 1 Required Friendliness of the physician 5 4 3 2 1 Required Quality of the service performed 5 4 3 2 1 Required Degree to which your concerns were addressed by the physician 5 4 3 2 1 Required Degree to which your concerns were addressed by the office staff 5 4 3 2 1 Required If you used our website, did you find it efficient and helpful? 5 4 3 2 1 Required If you require surgery, did you find the surgical coordination friendly and efficient? 5 4 3 2 1 Required The ease of checking out and paying for the appointment 5 4 3 2 1 Required In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices and procedures. How likely is it that you would recommend our office to your family members, co-workers, and friends? 5 4 3 2 1 Required Would you like to provide us with your contact information? Yes No Full Name: Phone Number: Email: Total Score By submitting this form you give consent for OSS to use your comments in any marketing or testimonial materials.
