Your comments are very important to us. Thanks for taking time to evaluate our service relationship with you.

The quality of the relationship between the physician and patient is one of the most personal and important there can be. This survey is intended to provide information that will help improve the quality of patient care provided by our physicians, nurses and office staff.

In recent weeks you have received medical services from our practice. We ask that you take a few moments to complete this evaluation of the care you received. Please feel comfortable being totally honest in your evaluation. You are not required to provide your name.

After completing the questions, please click "SUBMIT." Thank you!


What is the name of the physician primarily responsible for your care?
What is the name of the physician who referred you to one of our specialists? (If known)

Please describe yourself:
(or the patient if you are completing this survey on behalf of someone else)


Gender: Age:
Male: Female: 0-6 years
7-15 years
16-30 years
31-45 years
46-65 years
Over 65 years

Type of Health Coverage:
Medicare
Cigna/Healthsource
Blue Cross/Blue Shield
Wellport
TennCare
Self-Pay

Evaluate each of your experiences with our office as described below.


Please rate…

Excellent

Very Good

Good

Fair

Poor

Ease in reaching Diagnostic Center

Difficulty (or wait) in making an appointment

Convenience of office hours

Courtesy of our staff

Ease of our registration process

Comfort of our waiting areas

Respect for your privacy

Cleanliness of the office

Ease in getting questions answered

Availability of parking


About your physician.


Please rate…

Excellent

Very Good

Good

Fair

Poor

Physician's promptness in seeing you (time you waited to see our specialist)

Physician's promptness in seeing you in the office

Amount of time physician spent talking with you

Physician's willingness to answer your questions

Physician's personal manner (courtesy, respect, communication, friendliness)


About your nurse.


Please rate…

Excellent

Very Good

Good

Fair

Poor

Nurse's responsiveness to your needs

Nurse's ability to answer your questions

Professionalism of your nurse

Nurse's personal manner (courtesy, respect, communication, friendliness)

What is the name of your nurse?


Overall impressions


Please rate…

Excellent

Very Good

Good

Fair

Poor

Your overall satisfaction with the service of Diagnostic Center

The outcome of your medical care

Your attitude about the future of your health care

Likelihood you would recommend your physician/specialist to others


We value your comments and suggestions...

What did you like best about your care?

What are the most important things we can do to improve our services?


This section is optional...
If you wish for someone to contact you concerning your service experiences with us, please provide your contact information in the spaces below.

Your name:
Daytime phone:
Evening Phone:

Thank You

2205 McCallie Avenue • Chattanooga, Tennessee 37404-3230
(423) 698-2435 • (423) 697-6110 FAX

We protect our patients by ensuring the confidentiality of their medical information.
Click here to read our Notice of Privacy Practices for Protected Health Information.