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Appointments:
Click here to see a complete list of Boynton's phone numbers

(612) 625-3222 
 
 
Home > Feedback Form > Patient Feedback Form

 

Patient Feedback Form

We would like to hear about your visit to Boynton. It would help us identify areas that we are doing well and those that need improvement. If you prefer to speak to someone regarding your experience, you may call the Quality Assurance Department at (612) 625-5688.


Date of visit : Year
 

  1. In which department(s) were you seen today?

     
    Cashier
    Dental Clinic
    Eye Clinic
    Immunization
    Laboratory
    Massage
    Mental Health
    Nutrition
         		 Patient Accounting
    Pharmacy
    Primary Care
    Student Insurance
    Urgent Care
    Women's Clinic
    X-ray
    St. Paul Clinic

     

  2. Were you treated in a helpful/courteous manner by the following people?
     
      Yes No Not Applicable
    a. Check-in/appt. staff
    b. Referral staff
    c. MD, PA, or
    NP (Nurse Practitioner)
    d. Dentist, Hygienist
    e. Mental Health Therapist
    f. Pharmacy staff
    g. RN, LPN, Med. Asst.
    h. Lab staff
    i. X-ray staff
    j. Eye Clinic staff
    k. Pt Acct/Stud Insurance
    l.

         		 Other (specify)
     

 

  1. Did you make an appointment for your visit?
    yes no

  2. How long did you wait before you were seen?
    Not selected (Default)
    Less than 5 minutes
    5 - 15 minutes
    16 - 30 minutes
    31 - 45 minutes
    Other (specify)

     

  3. How would you rate the quality of the customer service you received?
    Not selected (Default)
    Excellent
    Good
    Fair
    Poor

     

  4. Did you feel the provider addressed your concerns and issues?
    Not selected (Default)
    Very much so
    Somewhat
    Not at all

     

  5. Please rate the importance of each of the following items:
     (3 = very important, 2 = somewhat important, 1 = not important)
    Courteous staff
    Ability to be seen at my convenience
    Appearance of facility
    To be seen on time by provider

     

  6. Your comments are most welcome and will be handled with discretion:

If this is a complaint, do you wish to be contacted by the Quality Assurance department for follow-up?
yes no

The following information is optional, but is required if you wish to be contacted.

Name:
E-mail:
Address:
City:
State:

Zip:
Phone:

 

 
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 Last modified on June 10, 2008