Thank you for taking the time to share your experience with us.

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* 1. Select your appointment type:

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* 2. How soon were you able to receive an appointment:

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* 3. Did we have a time or appointment that worked well for you?

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* 4. The clinician you saw for your visit:

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* 5. Did you receive an appointment with your clinician of choice?

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* 6. If you had an office visit, how much time do you estimate you spent in our office:

Please rate the following:

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* 7. The courtesy of the person who scheduled your appointment

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* 8. The friendliness of the receptionist

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* 9. The caring concern of our nurses/medical assistants

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* 10. The provider listened carefully to my concerns

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* 11. The instructions given to me for follow-up care were easy to understand

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* 12. Overall experience with our office

Please answer the following questions:

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* 13. Did someone from this provider’s office talk with you about your specific health goals and steps to achieve them?

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* 14. If you are a current smoker, were you provided with resources and/or counseling on how to quit?

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* 15. During your visit, did your care team provide enough information on any new or existing referrals and/or orders? (Labs, specialist referrals, x-ray, etc.)?

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* 16. Would you recommend the provider to others?

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* 17. If no, please tell us why:

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* 18. Is there anything we could have done to improve your visit?

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* 19. Is there anyone that stood out, or went above and beyond in providing excellent care for you?

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