On-line Survey

How Are We Doing?

Please take a few minutes to fill out this survey on the timeliness and quality of the service you received today. Hardee Family Medicine welcomes your feedback and your answers will be kept confidential. Thank you for your participation.

General Patient Information

In general what is the quality of your health?

How would you rate our concern for your privacy?

How often have you visited Hardee Family Medicine within the past year?

Schedule Your Appointment

Did you schedule an appointment by phone or did you routine follow-up?

If you scheduled an appointment, did you have to wait longer than expected to get scheduled?

How easy was it to make an appointment by telephone?

How long did you wait to speak to a scheduling staff member?

Was the person who scheduled your appointment courteous and helpful?

If you were seeking a referral to a specialist, was your request handled in a timely manner?

Day Of Your Appointment


How would you rate the courtesy of the staff at the reception desk?

How long did you wait in the reception area beyond your scheduled appointment time?

How long did you wait in the exam room before the physician appeared?

Which department(s) did you visit during your appointment?

The Nursing Staff

How would you rate the competence of the nurse who helped you?

How would you characterize the concern that the nurse showed for your problem?

Did the nurse respond to your requests within a reasonable period?

Physician or Physician Assistant


Were you able to see the provider of your choice?

Did you feel that your provider spent an adequate amount of time with you?

Mark the boxes that characterize the demeanor of your provider:

How would you rate the competence of your provider?

Did you feel that your provider's examination was thorough?

Please rate the clarity of the provider's explanation of your condition and treatment options:

How well did your provider include you in healthcare decisions?

Were your questions answered to your satisfaction?

Would you recommend this facility and its staff to your family and friends?

The Lab Staff

How would you rate the professionalism and competence of the person who took your blood and worked on your lab exam?

If you received a lab exam, please indicate the type(s) of lab exam you received:

If other exam, what was it?

If you received a lab exam, was the service prompt, comfortable, and courteous?

Additional Feedback

Please list any areas in which our service could be improved.

Please share any additional comments.

Personal Information

Providing the following information is optional.

First Name

Last Name

Street Address






Would you like someone to contact you regarding your responses on this survey?