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Microsoft Word - 20.84 KB]
First and Last Name
Line One of Address
Line Two of Address (If Any)
City, State, Zip
Dear {Mr./Ms.} [Last Name]
We at [Name of Clinician Organization] need your help. We want to improve the care we give you and other patients. We would like you to tell us about your experiences with the care you receive from [Doctor's Name] and our office.
The information that you give us will stay private. Your answers will never be seen by your doctor or anyone else involved with your care. Your doctor will not even know you helped us by answering these questions. You do not have to answer the questions. Your medical care will not change in any way if you say no.
If you are willing to help us, please answer these questions about the care you have received from [Doctor's Name] and our office in the last 12 months. This questionnaire should take about [Time] minutes or less of your time.
Please return the completed survey in the enclosed postage-paid envelope by [Month/Day/Year].
If you have any questions about this survey, please call [Contact Name] at (XXX) [XXX-XXXX]. All calls to this number are free. Thank you for helping to make health care at [Name Of Clinician Group] better for everyone!
Sincerely,
[Name of Person Representing Clinician Organization]
Nota: Si quiere una encuesta en español, por favor llame al (XXX) [XXX-XXXX].
