Everything Your Heart Desires

Patient Satisfaction Survey

At CANM, we place a premium on providing a pleasant, productive patient experience. We understand that your time is valuable and seek to make accessing our staff as convenient and stress-free as possible.

As part of our concerted effort to continually improve patient satisfaction, we monitor and review the practice of each physician at CANM. This evaluation includes the careful consideration of patient responses about our physicians’ and staff performance.

We encourage you to share thoughts and opinions and appreciate your willingness to participate in this survey. Thanks again for taking the time to complete and submit this form.

About Your Appointment: 1.) How Easy was it for you to obtain an appointment?

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor


Yes   No

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor


Excellent   Good   Fair   Poor

About Your Medical Care And Physician:

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor

Yes   No

Medication    Surgery    Other   


About Yourself:

Under 18    18-34    35-49   
50-65   65+   

Physician Referral    Family    Friend Internet    Insurance    Other   
 

Yes    No

About Us:

Excellent   Good   Fair   Poor

Excellent   Good   Fair   Poor

Contact Information:

In order to make certain we meet your expectations now and in the future, we will gladly follow-up with any concerns you may have. In order to facilitate this, we ask that you let us know how to contact you.

Please note: You are not required to furnish contact information in order to submit your feedback; however, we encourage you to do so, as we value your opinion and would appreciate the opportunity to converse with you personally.