UHZ Sport Medicine

We would like your opinion of UHZ physician and our staff. There are no right or wrong answers, rather indicators for us on what to improve regarding our service. This is a confidential survey. At your first convenience, please complete this form. Thank you very much for your time- customer satisfaction is our goal !

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• 1. Will you:
  	Extremeley Likely	Very Likely	Likely	Somewhat Likely	Not At All Likely
  Recomended UHZ to others
  Recomended your current physician UHZ to others

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• 2. Rate Our Services:
  	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
  Overall quality of services
  Scheduling an appointment
  Willingness of staff to meet your scheduling needs
  Convenience of office hours
  Registration staff friendliness
  Time spent in Reception Area
  Appearance of Reception Area
  Comfort of Seating
  Time spent in Patient Exam Room awaiting Physician
  Clinical Staff friendliness
  Insurance/Billing friendliness
  Insurance/Billing expertise

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• 3. Rate Your Physician:
  	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
  Amount of time spent with you
  Physician Friendliness
  Understanding Your Feelings
  Explanation of your Medical Condition
  Explanation of your treatment options
  Respect shown during appointment

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• 4. Rate Our Staff(Physician,Physician Assistant, Athletic trainers):
  	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
  Friendliness
  Understanding of your needs
  Respect shown to you
  Explanation of your tests and procedures

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• 5. Rate Your Telephonic Communication experience:
  	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
  Connection to the right person the first time
  Amount of time spent on hold
  Speed of returning your call
  Ease of connection with your physician during business hours

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• 6. Rate the building and office:
  	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
  Convenience of location
  Appearance of building
  Ease of finding your way to the front door of UHZ
  Ease of finding your way from room to room

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• 7. How did you select UHZ? Please, check all that apply.
  Doctor’s recommendation	Facebook	Print Ad - Magazine
  Friends/Family/Co-worker	Yellow Pages	HMO/PPO Provider List
  Google	Radio Commercial	Referral Service
  Yahoo	TV Commercial	Worker's Comp
  Website	Print Ad - Newspaper
  Other(Please Specify)

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• 8. Who is your current UHZ Physician?.

  John Uribe, MD	John Zvijac, MD	Keith Hechtman, MD
  Thomas San Giovanni, MD

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• 9. Is there a way we can be more accommodating while you wait?

  Yes	No
  Comments

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• 10. Are You:

  Male

  Female

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• 11. Are You:

  35-44	18-24	25-34
  65 or Older	45-54	55-64

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• 12. Have you visited our website: www.uhzsmi.com?

  Yes

  No

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• 13. Your opinion is important to us. Please share any other suggestions or concerns – thank you!

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