Clinic Survey

Exit this survey 

1. Date of Visit:

2. Clinic Site:

3. Reason for Visit (please choose one)

4. If other please list

5. I was seen in a timely manner

6. My needs were met to my satisfaction.

7. All of my questions were fully answered.

8. The facilities were neat and clean.

9. Services are available in my language.

10. Telephone calls are answered quickly.

11. I will recommend this clinic to others.

12. Front Desk Staff

13. Nurse or Medical Assistant

14. Exam Room Assistant

15. Clinician who did your exam

16. Post-Exam Counselor

17. Where did you learn about our clinic?

18. What could we do to improve your visit with us?

19. Optional Contact Information.