Bella Derma Dermatology Group

We honor and value our patients. In an effort to improve the delivery of our services, we would appreciate you taking a few minute to identifying any problems as well as those things which we are doing right! Your response will be confidential unless you choose to place your name on the survey. Name(optional) :________________________ Date:_______________

Satisfaction with patient care:

1. Are our phones answered promptly? 2. Was your hold time minimal? 3. Was the receptionist courteous and helpful? 4. Did you receive a reminder call about your appointment? 5. Were you informed prior to your appointment of any pre-payment requirements? 6. Was nurse courteous, helpful and compassionate? 7. Was your phone call returned in a timely manner? 8. Did you receive satisfactory answers to your questions from the staff? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Satisfaction with the physician:

9. Was the amount of time the doctor spent with you adequate? 10. Did he/she take time to answer your questions? 11. Did the physician provide the information you needed to understand your care? 12. Was the physician friendly, personable, and concerned? 13. Was the wait time in the exam room adequate? Yes Yes Yes Yes Yes No No No No No

Willingness to return to Bella Derma:

14. Would you return to this office? 15. Would you recommend this office to your family and friends? 16. Did the service you received meet our expectations? Yes Yes Yes No No No

Do you have any suggestions for improving our services? _____________________________________________