<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next strErrorUrl = "error.asp" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("survey1_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "survey", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(24) Dim arFormDBFields0(24) Dim arFormValues0(24) arFormFields0(0) = "comfortable" arFormDBFields0(0) = "comfortable" arFormValues0(0) = Request("comfortable") arFormFields0(1) = "parking" arFormDBFields0(1) = "parking" arFormValues0(1) = Request("parking") arFormFields0(2) = "holdtime" arFormDBFields0(2) = "holdtime" arFormValues0(2) = Request("holdtime") arFormFields0(3) = "clean" arFormDBFields0(3) = "clean" arFormValues0(3) = Request("clean") arFormFields0(4) = "atmosphere" arFormDBFields0(4) = "atmosphere" arFormValues0(4) = Request("atmosphere") arFormFields0(5) = "answers" arFormDBFields0(5) = "answers" arFormValues0(5) = Request("answers") arFormFields0(6) = "attentive" arFormDBFields0(6) = "attentive" arFormValues0(6) = Request("attentive") arFormFields0(7) = "Survey_Complete" arFormDBFields0(7) = "Survey_Complete" arFormValues0(7) = Request("Survey_Complete") arFormFields0(8) = "comments" arFormDBFields0(8) = "comments" arFormValues0(8) = Request("comments") arFormFields0(9) = "hoursbetter" arFormDBFields0(9) = "hoursbetter" arFormValues0(9) = Request("hoursbetter") arFormFields0(10) = "greeting" arFormDBFields0(10) = "greeting" arFormValues0(10) = Request("greeting") arFormFields0(11) = "phone" arFormDBFields0(11) = "phone" arFormValues0(11) = Request("phone") arFormFields0(12) = "hours" arFormDBFields0(12) = "hours" arFormValues0(12) = Request("hours") arFormFields0(13) = "billing" arFormDBFields0(13) = "billing" arFormValues0(13) = Request("billing") arFormFields0(14) = "chooseLocation" arFormDBFields0(14) = "chooseLocation" arFormValues0(14) = Request("chooseLocation") arFormFields0(15) = "name" arFormDBFields0(15) = "name" arFormValues0(15) = Request("name") arFormFields0(16) = "ontime" arFormDBFields0(16) = "ontime" arFormValues0(16) = Request("ontime") arFormFields0(17) = "recommend" arFormDBFields0(17) = "recommend" arFormValues0(17) = Request("recommend") arFormFields0(18) = "respect" arFormDBFields0(18) = "respect" arFormValues0(18) = Request("respect") arFormFields0(19) = "staffcom" arFormDBFields0(19) = "staffcom" arFormValues0(19) = Request("staffcom") arFormFields0(20) = "calls" arFormDBFields0(20) = "calls" arFormValues0(20) = Request("calls") arFormFields0(21) = "time" arFormDBFields0(21) = "time" arFormValues0(21) = Request("time") arFormFields0(22) = "reception" arFormDBFields0(22) = "reception" arFormValues0(22) = Request("reception") arFormFields0(23) = "hold" arFormDBFields0(23) = "hold" arFormValues0(23) = Request("hold") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If FP_SaveFieldToDB fp_rs, Now, "timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close Session("FP_SavedFields")=arFormFields0 Session("FP_SavedValues")=arFormValues0 Response.Redirect "thanks.asp" End If End If %> Your Opinion Is Important to Us
HomeLocationsServicesInsuranceGeneral InformationPatient Survey

Patient Satisfaction Survey

Your input is very important to us. We are here to serve you and meet your needs. By letting us know what was done right and what can be done better, we can continue to improve our service to you and our other patients.
- Eric Novicki, Administrator
Please feel free to be specific about any employee or situation. All responses will be strictly confidential.



Highest
Positive		 - Lowest
Negative


5 4 3 2 1
1) Are you given a pleasant greeting when you arrive?
2) Are you treated courteously and with respect?
3) Does the staff spend adequate time with you?
4) Are you satisfied with the answers to your questions?
5a) Are our office hours convenient?
5b) If our office hours are NOT convenient, what hours would be helpful?
6) Is there ample parking?
7) Is our office cleaned properly?
8) Do we answer the phone properly?
9) Do you feel comfortable with our clinic and staff?
10) Is our staff attentive?
11) Is the atmosphere created by our clinic and staff enjoyable?
12) Are you able to speak before you are put on hold?
13) Is the amount of time you are kept on hold appropriate?
14) Do we return calls promptly?
15) Do we see you on time?
16) Is our reception area comfortable?
17) Do we give you the help you need with billing questions?
18) Would you recommend others to our office? Yes - No
19) Do you have any comments about any of our staff (good or bad) that you would like to share?
20) If you have any additional comments or suggestions:

Thank you for taking the time to complete this questionnaire.
Name (Optional)