Tri State MFM
HomePrenatal CarePhysicians and StaffFetal DiagnosisFetal TherapiesDiabetesGenetic CounselingMaternal TransportTestimonialsPatient RegistrationPatient Survey
 


We are always striving to provide the best possible customer service to our patients. We value your opinion and use your feedback as an opportunity to reinforce great customer service. Equally important is to know when we didn't meet your needs and why, in order that we may have the opportunity to correct our actions. Thank you in advance for your time and efforts to let us know how we are doing.

Pam McClintock
Practice Administrator

First Name:
Last Name:
Address:
Phone:
Date of visit:
I was referred to the practice by:
  If other, please specify:
I was referred for the following services:
  If other, please specify:
Please rate the following questions (do not include services received from the Seton Center)
Ease of making an appointment: Click the arrow for other choices.
Ease of check in: Click the arrow for other choices.
Length of time spent waiting in
the reception area: 		Click the arrow for other choices.
Length of time spent waiting in
the exam room: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the scheduler: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the nursing staff: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the telephone triage nurse: 		Click the arrow for other choices.
The courtesy and respect of the physician: Click the arrow for other choices.
The amount of time spent with the physician: Click the arrow for other choices.
The physician answered my questions: Click the arrow for other choices.
The physician's instructions were clear
and easy to understand: 		Click the arrow for other choices.
Telephone messages were returned in a timely manner: Click the arrow for other choices.
Test results were reported in a reasonable amount of time: Click the arrow for other choices.
Procedures and tests were explained clearly: Click the arrow for other choices.
Ability to contact the physician
on call after hours: 		Click the arrow for other choices.
Overall comfort of the office: Click the arrow for other choices.
Directions and signs to office/facility
are easy to follow: 		Click the arrow for other choices.
Overall satisfaction with the practice: Click the arrow for other choices.
Overall satisfaction with the quality of
my medical care: 		Click the arrow for other choices.
I would recommend this practice to others:


My office visit included:



Counseling
The provider who cared for me
during my visit was:










My age is:
Please answer the following regarding GSH-Seton Center, if applicable:
The courtesy, respect and helpfulness
of the front desk receptionist: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the sonographer: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the genetic counselor: 		Click the arrow for other choices.
The courtesy, respect and helpfulness
of the diabetic educators: 		Click the arrow for other choices.
Appointment available within a reasonable amount of time: Click the arrow for other choices.
We value your opinion as to how we can improve your care. Are there any additional comments you'd like to provide us?
May we contact you regarding the above?
For verification purposes please type the phrase below in the area designated to the right then click the submit button.