Form 0917-0036 Physician/Dentist Customer Service Questionnaire

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Physician/Dentist Customer Service Questionnaire

1. During your last visit, do you feel your doctor/dentist listened to your concerns?

Strongly Agree Agree Neutral Disagree Strongly Disagree

2. During your last visit, did your doctor/dentist provide you with their full attention?

Strongly Agree Agree Neutral Disagree Strongly Disagree

3. During your last visit, do you feel your doctor/dentist was up-to-date on current medical information?

Strongly Agree Agree Neutral Disagree Strongly Disagree

4. During your last visit, do you feel your time with the doctor/dentist was well spent?

Strongly Agree Agree Neutral Disagree Strongly Disagree

5. During your last visit, did you see your doctor/dentist wash their hands (i.e. use soap and water and/or use hand sanitizer)?

Yes No

6. (Optional)

If you would like to provide the name of the doctor/dentist you were seen by at your last visit, please do so in the space provided.

_______________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.