* 1. Which office did you visit?

* 2. When scheduling your appointment, how long did you have to wait to speak with a scheduling staff member?

* 3. Was the person who helped schedule your appointment professional, courteous and helpful?

* 4. Upon entering our office, was the receptionist staff member that helped you professional, courteous and helpful?

* 5. After checking in, how long did you wait in the reception area before being called by a medical assistant?

* 6. If your wait in the reception area was longer than 20 minutes, were you advised of the delay?

* 7. Was the medical assistant that helped you professional, courteous and helpful?

* 8. Which provider did you see during your visit?

* 9. Were you able to see the provider of your choice?

* 10. How long did you wait in the examination room for your provider?

* 11. Did the provider spend enough time with you during your visit?

* 12. From the list below, please indicate the demeanor of the provider during your visit (choose all that apply):

* 13. Did the provider listen to your concerns and questions carefully?

* 14. Did the provider address your questions and concerns thoroughly and properly?

* 15. Did you feel that the provider's examination was thorough and complete?

* 16. Please rate the clarity of the provider's explanation of your condition and treatment options:

* 17. During your visit, did you speak with a Registered Nurse?

* 18. Was the Registered Nurse that helped you professional, courteous and helpful?

* 19. Were your questions for the Registered Nurse answered to your satisfaction?

* 20. During your visit, did you receive a lab examination? If yes, please indicate the type of lab:

* 21. Was the lab technician that helped you professional, courteous and helpful?

* 22. During your visit, did you meet with a member of the Billing Office? If yes, was the Billing Office staff member that helped you professional, courteous and helpful?

* 23. How would you rate your overall experience at Brunswick Hills Ob/Gyn?

* 24. What is the likelihood you would return to Brunswick Hills Ob/Gyn?

* 25. What is the likelihood you would recommend Brunswick Hills Ob/Gyn to friends and family?

* 26. Would you be interested in any of the following services if offered at Brunswick Hills Ob/Gyn? Select all that apply:

* 27. In the space provided below, feel free to add any constructive comments that will help Brunswick Hills Ob/Gyn improve:

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