Blair Orthopedic Associates and Sports Medicine

Satisfaction Survey

Thank you for choosing Blair Orthopedic Associates & Sports Medicine.

Please take a few minutes during your visit today to complete this survey and return it to us when you check out.

We will use your responses to continue to improve upon and provide for a pleasant office experience.

Please indicate how you feel we did in these areas:

Excellent

Good

Average

Poor

Availability and convenience of space in the parking lot:

Suggestions for improvement:

Instruction from BOA staff and the use of signs and carpet colors to assist me in finding my way through the facility

Suggestions for improvement:

The level of courtesy and helpfulness extended to me by BOA staff:

Suggestions for improvement:

Clarity of the explanation of my financial responsibilities and BOA billing procedures

Suggestions for improvement:

Comfort of the waiting area:

Suggestions for improvement:

Length of time I waited to see the doctor:

Suggestions for improvement:

Clarity of the doctor’s, nurses, and/or physician assistant’s explanation of my problem, treatment, and outcomes

Suggestions for improvement:

I would recommend Blair Orthopedic Associates & Sports Medicine to others:

Yes

Additional Comments:

Help Us Improve Our Website!

Very Likely

Likely

Unsure

Not at All

How likely would you be to complete your medical history form through our secure website prior to arriving for your appointment?

How likely would you be to request your medical records and/or x-rays through our website?

How likely would you be to use our website for orthopedic education?

How likely would you be to request an appointment using our website?

How likely would you be to establish and maintain your medical history using our website?

How likely would you be to pay a bill using our website?

What else would you like to see on our website?

How did you become aware of us? (Check all that apply)		What factors influenced your decision to see us? (Check all that apply)
	Family physician.		Reputation
	Recommended by a family member or friend		The doctor’s level of education and training
	Yellow Pages		The scope of services that we offer
	Website		Location
	Newspaper
	Screening
	Brochure
	Orthopedic Education Fair
	Sports Team / Athletic Event
	T-Shirt
	Other

Would you like our Customer Service Representative to contact you about your visit?

Yes

If yes, please list:

Name

Phone Number: