Rocky Mountain Cardiology, PC
Roy W Thompson, MD Nelson P Trujillo, MD Charles P Rogers, MD
Bryan J Reynolds, MD Daniel S White, MD John A Schutz, MD
James B Chapman, MD Sameer Oza, MD John R McNeil, MD
  Molly Ward, MD  
Rocky Mountain Cardiology, P.C.
2505 4th Street
Boulder, CO 80304
tel: 303-442-2395
fax: 303-442-1073
United Medical Building
2030 Mountain View Avenue
Suite 200
Longmont, CO 80501
tel: 303-702-5958
fax: 303-702-5960 		Community Medical Center
1000 W. South Boulder Road
Suite 216
Lafayette, CO 80026
tel: 303-604-4646
fax: 303-604-4644


PATIENT SATISFACTION SURVEY

Dear Patient:

In an ongoing effort to improve your experience with our office, we would greatly appreciate it if you would take a few moments to answer the following questions.

Thank you!

(1) Which location did you visit?

    Boulder Longmont Lafayette

What was the date of your visit?

(2) What was the reason/purpose of your visit?

    If Other, please specify

(3) Was this your first visit to our office?

    Yes No

(4) When you arrived at our office, were you greeted in a prompt and courteous manner by the receptionist?

    Yes No

    If No, please explain

(5) Did you encounter any difficulty in making the appointment for today's visit?

    Yes No

    If Yes, please explain

(6) Did you find the appointment time frame to be acceptable?

    Yes No

    If No, how long did you wait to get an appointment?

(7) How long did you have to wait before being seen?

(8) Did the nurses/medical assistants treat you in a courteous and professional manner?

    Yes No

    If No, please explain

(9) If you saw the doctor, did he treat you in a courteous and professional manner?

    Yes No

    If No, please explain

(10) Were all your questions answered?

    Yes No

    If No, please explain

(11) Overall, how would you rate your visit to our office?

(12) Would you recommend our office to a friend/relative?

    Yes No

Additional Comments


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