Adult Pediatric Urology & Urogynecology, P.C. Patient Satisfaction Survey Name First Last Email Phone We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time. Please circle how well you think we are doing in the following areas GREAT 5 GOOD 4 OK 3 FAIR 2 POOR 1 Ease of getting care: Ability to get in to be seen Hours clinic is open Prompt return on calls Waiting: Time in waiting room Time in exam room Waiting for test results Staff: Provider: (Physician, Physician Assistant, Nurse Practitioner) Listens to you Takes enough time with you Explains what you want to know Gives good advice and treatment Nurses and Medical Assistants Friendly and helpful to you Answers your questions All other staff: Friendly and helpful to you Answers your questions Confidentiality: Keeping my personal information private Referral: The likelihood of referring your friends and relatives to us Which provider did you see?* Which office were you seen in?* 10707 Pacific St., Omaha3434 W Broadway, Council Bluffs Additional comments or concerns you would like to share with us: Would you like us to contact you in regards to this survey? Yes No Phone This field is for validation purposes and should be left unchanged.