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* 1. Providers/Physician Seen

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* 2. Patient Name

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* 3. Patient Email Address

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* 4. Date Visited

Date

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* 5. Please rate your satisfaction with the promptness with which your calls were answered.

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* 6. Please rate your satisfaction with the courtesy of the staff over the telephone.

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* 7. Please rate you satisfaction with the ease of making appointments for checkups.

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* 8. Please rate your satisfaction with the ease with which you were able to make appointments for problems.

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* 9. Please rate your satisfaction with the amount of time your physician spent with you.

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* 10. Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

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* 11. Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

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* 12. Please rate your satisfaction with the general appearance of the center.

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* 13. Please rate your satisfaction with the courtesy of the medical assistants during your visit.

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* 14. Please rate your satisfaction with the overall quality of your care.

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* 15. Please rate your satisfaction with the availability of a physician after regular office hours.

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* 16. Please rate your satisfaction with the personal concern shown to you by your physician.

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* 17. Please rate your satisfaction with explanations of tests or procedures performed.

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* 18. Please rate your satisfaction with the instructions for taking medications.

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* 19. Please rate your satisfaction with your opportunity to ask questions.

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* 20. Please rate your satisfaction with the answers to your questions.

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* 21. Please rate your satisfaction with the explanation of payment.

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* 22. Please rate your satisfaction with the results of your care.

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* 23. Additional comments are welcomed.

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