Date of Visit (month/date/year)
Doctor/NP/PA who saw you?
(Select One) Jason Bennett, MD Michael Bennett, MD Adam Blickley, MD Brooke Bollin-Richards, MD Ruth Brandt, MD Roger Edvenson, MD Jeffrey Frank, MD Kate Haehnel, CURN, MS, FNP Kathleen Hascher, FNP-BC Ziomara Hidalgo, PA-C Judith Hiemenga, MD Robyn Hubbard, MD Elizabeth Luce, MD Charles Newton, MD Jamie Rodriquez, RNC, WHNP-BC Curtis Struyk, MD Rodman Taber, MD Jane Thiel, APRN, WHNP-BC Anita VanDeBurg, MD Douglas VanDrie, MD
Which division did you visit?
(Select One) Female Pelvic Medicine & Uro OB/GYN Specialists
How long have you been a patient at this practice?
(Select One) 1st visit Less than 1 year 1 – 5 years More than 5 years
How satisfied are you with the following?
Visit Overall
(Select One) Excellent Acceptable Poor Not Applicable
Appointment available within a reasonable amount of time
(Select One) Excellent Acceptable Poor Not Applicable
Appearance of office
(Select One) Excellent Acceptable Poor Not Applicable
Wait time in office
Are you satisfied with this amount of time?
(Select One) Excellent Acceptable Poor Not Applicable
Amount of time spent with doctor/NP/PA
(Select One) Excellent Acceptable Poor Not Applicable
Doctor/NP/PA understanding the special needs and condition of women
(Select One) Excellent Acceptable Poor Not Applicable
Front office staff friendly and courteous
(Select One) Excellent Acceptable Poor Not Applicable
Billing staff answered all your questions
(Select One) Excellent Acceptable Poor Not Applicable
Name
Contact Phone
Email Address
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