University Surgical: Home

University Surgical Associates is interested in your comments and suggestions regarding our practice and your experience. If you’ve recently visited one of our offices for an appointment, please take a moment to complete the survey below. Your input is invaluable and will assist us in providing better patient care. If you have any questions or your concerns are of an urgent nature, please contact us immediately at (423) 367-0466 or toll-free at (800) 833-0572.

Patient gender?

Male
Female

Patient age?

Infant - 10
11 - 17
18 - 24
25 - 35
36 - 45
46 - 65
66 or Older

Patient ethnic background?

Black (Not of Hispanic Origin)
Hispanic / Latino
White (Not of Hispanic Origin)
American Indian / Alaskan Native
Asian / Pacific Islander
Multi Race

Years a USA patient?

1st Visit
0 - 1 Year
2 - 5 Years
6 - 10 Years
11 - 15 Years
Over 15 Years

How did you hear about University Surgical Associates?

Friend / Relative
Physician Referral
Yellow Pages
Radio / Television
Billboard
Internet
News
Other - Please Specify:

Which USA location did you visit today?

Which USA physician did you meet with today?

I found it easy to schedule an appointment.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

Were you placed on hold while scheduling your appointment?

Yes
No

Did the scheduler pick up promptly?

Yes
No
N/A
Approximate Wait:

The scheduler provided me with complete instructions pertaining to my visit.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

Was your preferred appointment time honored by USA?

Yes
No, I was delayed 1 week
No, I was delayed 2 weeks
No, I was delayed more than 3 weeks

Did the receptionist at the front desk greet you immediately upon arrival?

Yes
No
Problem Incurred:

How much time passed before you were greeted by a receptionist?

I was greeted immediately
Less than 30 seconds
1 - 2 minutes
3 - 5 minutes
More than 5 minutes

Were you asked to complete paperwork today?

Yes
No

I found the forms easy to fill out.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

The waiting room was clean and professional in appearance.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

How much time passed in the waiting room before you were called for your appointment?

0 - 10 minutes
11 - 20 minutes
21 - 30 minutes
31 - 40 minutes
More than 40 minutes

I was greeted by the nurse in a friendly manner.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

The nursing staff was knowledgeable in answering my questions.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

My physician was friendly and courteous.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

My physician spent adequate time with me.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

My physician listened to my concerns.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree
Problem Incurred:

If you were scheduled for a procedure today by your physician, were you provided adequate instructions by USA's staff for your surgery?

Yes
No
N/A
Problem Incurred:

If the physician you met with today is not available at this location, would it affect your choice of physicians?

No, I would see this physician no matter the location.
Yes, I would request another USA physician at this location.
Yes, I would NOT choose another USA physician, but rather a physician outside the USA practice.

I would recommend USA to a family member / friend.

Strongly Agree
Somewhat Agree
Undecided
Somewhat Disagree
Strongly Disagree

How can we improve our service?

Please rank the following on a scale of 1 to 5, 1 being poor and 5 being excellent. (Do not answer if you have not yet experienced that categeory.)
	Poor		Excellent
	1	2	3	4	5

Directions to office
Ease of access to office
Overall telephone etiquette
Friendliness of office staff
Nursing care
Physician care
Billing / Collections staff
Billing / Collections procedures
Patient education materials
USA Web site
Explanation of future exams
Explanation of future procedures
Post-appointment instructions
Medical records assistance
Were you treated with concern
Overall experience at USA