Consultant Survey

Consultant's Name: *

* Indicates required field

Consultant's Speciality *

Would you return to this consultant for future problems? *

Yes No Not Sure

Would you recommend this consultant to friends and family? *

Yes No Not Sure

Did the consultant adequately address the condition you were referred to them for evaluation? *

Yes No Not Sure

Do you agree with the assessment and recommendations of the consultant? *

Yes No Not Sure

Did the consultant provide you with a clear PLAN to address your condition? *

Yes No Not Sure

Did the consultant provide you with written (or electronic) instructions regarding your care plan? *

Yes No Not Sure

How would you rate the amount of time the consultant spent with you? *

The consultant spent as much time with me as I needed. The consultant spent enough time with me to evaluate my condition, but that was it. The consultant was in and out of the room. The consultant only spent a few minutes with me.

Can you estimate the amount of time that this consultant spent with you? *

How would you rate the time it took to get in to see the consultant (time between the referral and the appointment date). *

Can you estimate the amount of time between the time the referral was made and when you saw the specialist? *

How would you rate the time you had to wait to see the consultant at their office (wait time in the waiting room or exam room). *

Did your consultant schedule you for any procedures or tests (This includes surgery / lab test / ultrasound / X-ray / MRI / etc.)? *

Yes No Not Sure

If you did have a procedure/test, where was it done? (Chose all that apply) *

if you had a procedure / test, did the consultant offer to order the procedure or test at Mercy Medical Center? *

Yes No Not Sure

If you had a procedure / test, was the decision as to where it was performed: (Select all that apply) *

Your decision (Your Preference) Consultants decision (Also Your Preference) Consultants decision (Not Your Preference) Consultant only gave you one option.

Comment *

Your Name: *

Your Email (optional): *

Your Phone Number (Optional): *