Patient Survey

Welcome to our practice. You are very important to us, and we value your opinions and comments regarding our medical office. Your answers to the survey below will assist us in continuing to provide the highest quality of medical care available.

Thank you for your assistance.

1 - Poor   2 - Fair   3 - Good   4 - Very Good   5 - Excellent   N/A - Not Applicable


Contact Information
* Your Name: * Your E-Mail Address: * Your Phone Number:




1. When I telephoned to make an appointment, I was greeted with courtesy and respect.
2. I was assisted in finding a suitable appointment time.
3. When I telephoned for my appointment, I did not have to remain on hold for longer than three minutes before I spoke to a staff member.
4. I received adequate instructions on how to find the office.
5. The office was conveniently located.
6. The reception area is neat and comfortable.
7. There is adequate seating available.
8. There is current and interesting material to read.
9. I was greeted when I arrived and the staff explained office policies and procedures in clear, easy to understand terms.
10. I did not have to wait in the reception area for very long.
11. Confidential conversations were not audible from the reception area.
12. Each staff member has a neat, professional appearance.
13. The staff members were able to answer my questions.
14. The nurses were accessible.
15. The staff member who escorted me to the treatment area was cordial and professional in manner.
16. When my doctor greeted me he made me feel important.
17. My doctor explained what he was doing while he was examining me.
18. My doctor was accessible.
19. The procedure for receiving a laboratory test or diagnostic report was explained to me and easy to understand.
20. I recognized the high quality of the laboratory services.
21. The office’s procedures for billing were clearly explained to me.
22. I was given a thorough explanation of my financial obligations.
23. My financial counselor was friendly and courteous.
24. I felt that the prices were a good value for the services provided.
25. I was given the opportunity to schedule my next visit before I left.
26. I enjoyed the atmosphere and décor of the office.
27. I had a positive overall experience.
28. I would tell someone else about the positive experience I had today.
29. I would refer a friend or relative to this practice.
30. Please select the reason for your visit today:







If you are a new patient, please review our New Patient page.

Making miracles happen, one couple at a time.
Dominion Fertility
46 S Glebe Rd # 301
Arlington, VA 22204
USA
Phone: 703-920-3890
Fax: 703-892-6037