1. General Information

Patient Name*

Date of Appointment*

Where was your appointment?*
Select One1611 W Harrison St, Chicago, IL 606122450 S Wolf Rd, Westchester, IL 601542011 York Rd, Oak Brook, IL 60523
Email*

How did you hear about us?*
Doctor's OfficeFriend / FamilyInternetSocial Media

2. Office Staff

How easy was it to set up an appointment with our staff?*
ExcellentGoodUnsatisfactory
Was my phone call returned within 48 hours?*
ExcellentGoodUnsatisfactory
Was the staff courteous and helpful?*
ExcellentGoodUnsatisfactory
We are always looking at ways to recognize excellence among our staff members. If you’ve had an exceptional experience and want to recognize one of our staff members for outstanding service, please take a moment to share.

3. Facility

How easy was it to get to our clinic?*
ExcellentGoodUnsatisfactory
Was the clinic environment efficient?*
ExcellentGoodUnsatisfactory

4. Doctor

How long did you wait to see Dr. Singh?
20 minutes or less40 minutes or less40 minutes or more
Dr. Singh described the diagnosis in a slow, clear and concise manner*
ExcellentGoodUnsatisfactory
Dr. Singh listened attentively to me while I described the reason for my visit*
ExcellentGoodUnsatisfactory
Dr. Singh patiently answered my questions and advised me of the next step in my treatment process.*
ExcellentGoodUnsatisfactory
How likely are you to recommend Dr. Singh to family or friends?*
Extremely likelyVery likelySlightly likelyNot at all likely
Overall, were you satisfied with your experience*
SatisfiedDissatisfied
What changes would most improve our office?

5. Website

How easy is our site to navigate?*
ExcellentGoodUnsatisfactory
How clear is the information available on our website?*
ExcellentGoodUnsatisfactory
How can we improve the site?*

Any other comments or suggestions you might have to help us improve our service

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