Allergy Diagnostic & Treatment Center · 33 Overlook Road, Ste #307, Summit N.J. 07901
Voice (908) 522-9696· Fax: (908) 522-3070
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Online Patient Satisfaction Form:

Thank you for choosing our practice for your medical care. We would like to offer you the best medical care possible and we value your opinions regarding our practice. Please take a few minutes to complete this survey and we will personally review it. Please do not hesitate to offer any comments that may help this practice to be better for you and others.

Receptionist/Office Manager

Appointment availability:
Poor Fair Good Very Good Excellent Does not apply
Ease of getting through to the receptionist by phone:
Poor Fair Good Very Good Excellent Does not apply
Courtesy and professionalism of the receptionist:
Poor Fair Good Very Good Excellent Does not apply
Receptionist’s efficiency, ability to answer your questions:
Poor Fair Good Very Good Excellent Does not apply
Courtesy and professionalism of the Office Manager:
Poor Fair Good Very Good Excellent Does not apply
Office Manager's efficiency, ability to answer your questions:
Poor Fair Good Very Good Excellent Does not apply

Nurse/Medical Assistant

Courtesy and professionalism of the nurse/medical assistant:
Poor Fair Good Very Good Excellent
Nurse/medical assistant’s ability to explain medical information and answer your questions, including Patient Information sheets, handouts, etc.:
Poor Fair Good Very Good Excellent
The quality of care of the nurse or medical assistant:
Poor Fair Good Very Good Excellent
Ease of getting through to the nurse or medical assistant by phone:
Poor Fair Good Very Good Excellent Does not apply
Length of time waiting for allergy shots or SLIT pickup:
Poor Fair Good Very Good Excellent Does not apply

Doctor/Physician's Assistant/Nurse Practicioner

Who cared for you this visit?

Explanation of what was done for you by the doctor, PA, or NP:
Poor Fair Good Very Good Excellent Does not apply
The quality of care of the doctor, PA or NP:
Poor Fair Good Very Good Excellent Does not apply
The personal courtesy, friendliness, and sensitivity of the doctor or PA-C:
Poor Fair Good Very Good Excellent Does not apply

Overall

The comfort and cleanliness of the office:
Poor Fair Good Very Good Excellent
Length of time waiting in the office for your visit:
Poor Fair Good Very Good Excellent Does not apply
The visit overall:
Poor Fair Good Very Good Excellent
Will you be returning to the practice?:
Yes (follow-up) Yes (unscheduled) Uncertain No (no need) No (unhappy with practice)
(If no, please explain in Comments section below)
I would recommend this practice to my friends:
Yes Maybe No
(If no, please explain in Comments section below)

Personal Information (Optional)

First Name: M.I.: Last:
Date of visit:

Phone # E-mail:

Your comments (optional):