Rate Your Specialist Form - Specialists' Evaluation By Patients
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How To Use This Form:  You may write by hand or type the information in the boxes then print the form

 

Specialists

Allergy &
Immunology
Berger, William E. MD
364-2900
Carr, Warner W, MD

Hsu, Yu Luen, MD

Liao, Otto Y, MD
452-3730

Lin, Chao-I, MD
Nguyen, Roger L, MD
Sugar, Mark S, MD
Turk, Arthur, MD

Venkat, Geeta, MD
364-3551

 Audiology
Dr. Colucci
830-5770

Cardiology
Feigofsky, Suzanne, MD
Fortman, Daniel, MD

Dermatology
Evans, Tanya, MD
707-5734

Goldberg, Glenn, MD
770-8115

Endocrinology
Ballani, Piya, MD
Dhillon, Kimvir, MD
Geier, John, MD
Tran, Michael, MD
 

 

  


Patient Name
 

   First MI       Family

Referring Doctor
(Primary Care Provider)

   First MI       Family    
   


Specialist Name  

  First MI       Family


Specialty

  


Assistant Name
  First Title   Ext.


Appointment
  Date  Time    Am    PM 


Center/Clinic   

 


Address
  Street

  City   State   Zip


Telephone No.
  Area Code   Office  Toll Free
   
 

Practice & Specialist Evaluation By Patients
On a Scale  1-10, 10 being best, please rate the following:

The Specialist's Care Provider's Practice

Rating
  Your general impression of the practice

  The registration service
  Receptionist: Courteous, knowledgeable, response to your needs
  Was your scheduled appointment kept on time?
  Your waiting period to see the care provider
  Billing and financial information: Clear or confusing
  Patient Forms: Easy to read
  Your overall rating for this specialist (care provider)
  Would you refer this specialist to others?   Yes  No  

General Comments (you may type up to 10 lines):

Gastroenterology

Gynecology

Infectious Disease

Nephrology

Neurology

Obstetrics/Gynecology

Oncology

Ophthalmology

Ear/Nose & Throat

Pain Management

Podiatry

Pulmonary Disease

Rheumatology

Surgery
General

Surgery
Neurological

Surgery
Orthopedic

Urology

  
 
 

Patient Signature: ________________________________     Date:      /         /         

Print Your Evaluation Form and Give It To Your Primary Care Provider or referring Doctor/Therapist

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