Doctor Survey

Dear Physician,

Your opinions and perceptions about the way we provide care for your patients and handle your referrals to us are important. We would like to know how you feel about our services and the way we communicate with you.

Please take a few minutes of your time to help me by answering the following questions.  All of your individual responses will be kept strictly confidential.

Thank you in advance for your help.

Sincerely,

Arati Dunbar, M.D.

On a scale of 1 - 5 with 5 being excellent and 1 being poor, please rate our performance on each item by circling the appropriate number. If an item is not applicable, please circle not applicable (NA).

We welcome your comments.

		Rating Scale	Comments
1	Scheduling of appointments for your patients	1 2 3 4 5 NA
2	Courtesy of the office staff to you	1 2 3 4 5 NA
3	Courtesy of the office staff to your patients	1 2 3 4 5 NA
4	Courtesy of Dr. Dunbar to you	1 2 3 4 5 NA
5	Courtesy of Dr. Dunbar to your patients	1 2 3 4 5 NA
6	Your impression of Dr. Dunbar’s:
	Knowledge of medicine	1 2 3 4 5 NA
	Reports provided to you	1 2 3 4 5 NA
	Explanations/ reports given to your patients	1 2 3 4 5 NA
	Timeliness in providing reports	1 2 3 4 5 NA
7	Would you recommend us to other physicians?	Yes No	If no, please tell us why
8	How can we improve the way we work with you?
9	How can we improve the way we work with your patients?
10	How many patients have you referred to orthopaedic surgeons
	in the past month?
	in the past six months?
	in the past year?
11	Has the volume of referred patients increased , decreased or remained the same ?
	Why?
12	May we send you educational materials on orthopaedic topics for patients?	Yes No
The following information is optional but desirable
13	We would appreciate some information about you.
	The number of physicians in your medical group
	The number of physicians from your medical group who refer to this practice
	The names of managed care groups with which you contract
	Name
	Address
	City
	State
	Zip Code
	Telephone Number
	E-Mail Address