SMPC Referring Physician SURVEY

SMPC SURVEY: Please answer all questions as best as you can. Thank you for participating!

1. What are your expectations when sending patients to SMPC ?

2. Do you receive patient documentation/notes in a timely manner?
   Yes
   No
   NA…no patients referred at this time

3. If you don't schedule your patient's directly, do you want to be notified of your patient’s appointment date with SMPC after
    it has been set up?
   Yes
   No
   NA…no patients referred at this time

4. How do you feel SMPC is meeting the needs of your patients?
   a. Exceeds expectations
   b. Meets Expectations
   c. Does not meet expectations
   d. NA not currently referring

Comments:

5. Are you satisfied with the level of customer service related to the followings:

	Yes	No	NA not currently referring
a. Ease of Scheduling
b. Cooperation/ of SMPC office staff
c. Prompt response to requests for information

Comments:

6. Are your patients satisfied with their care/customer service related to followings:

	Yes	No	NA not currently referring
a. Ease of scheduling
b. Wait times
c. Office environment
d. Expectation/explanation of appointment
e. Attentiveness of physician
f. Care provided by nursing staff

Comments:

7. Do you utilize physical and behavioral therapy services provided by SMPC?

	Yes	No
Physical Therapy
Behavioral Health

Comments:

8. Would you like more information on SMPC: Check all that apply
   SMPC appointment pads
   SMPC online/fax referral forms
   SMPC Diagnosis and Treatment Sheet
   Office visit from Physician/CC/PA
   Information on how to obtain pain CEU credits for your staff
   None

Your office contact name, e-mail or phone# if you would like additional information

9. Final comments on how we can improve our service:

10. Your office specialty (ex: family, etc...)