Clay-Platte Family Medicine Clinic Patient Satisfaction Survey

1. We Want to Know about YOU:

1. Who is your primary healthcare provider?

	Choose one:
Our Providers:	Who is your primary healthcare provider? Our Providers: Choose one:

2. What is your gender?

What is your gender? Male

Female

3. What is your age range in years?

What is your age range in years? 0-17

18-24

25-34

35-44

45-54

55-64

65-74

over 75

4. How long have you been a patient at Clay Platte Family Medicine Clinic?

How long have you been a patient at Clay Platte Family Medicine Clinic? 0-6 months

7-12 months

1-2 years

3-5 years

more than 5 years

form {display:none;} #jserror {text-align:center;margin-top:50px;}Javascript is required for this site to function, please enable.