Geriatric Care Patient Satisfaction Survey
Patient Name
Patient Age
Date of Visit
Name of Caregiver (if applicable)
Experience with Our Geriatric Care Service
1. How would you rate the courtesy and respect shown by our staff?
Excellent
Good
Fair
Poor
2. Was your wait time reasonable?
Yes
No
3. Did you feel comfortable during your visit?
Yes
No
4. Please rate your overall satisfaction with the care received.
Very Satisfied
Satisfied
Neutral
Dissatisfied
Would you recommend our services to others?
Yes
No
Additional Comments or Suggestions