Summerville Survey English Español Question Title * 1. Please select your provider Jose Justiniano Ayala,MD Denise Carson,FNP Danielle Townsend, Dietician Dee Harwell, Dietician Shalane Lamb, FNP Question Title * 2. How affordable do you find your sliding scale fees? Very Affordable Affordable Not Affordable Question Title * 3. If fees are not affordable, would you like one of our case workers to contact you? Yes No Question Title * 4. Please enter your name and number if you would like to be contacted. Question Title * 5. Insurance Yes No Question Title * 6. Age 0-17 18-35 36-53 54-71 72+ Please select how well you think we are doing. Question Title * 7. EASE OF GETTING CAREScheduling, hours and location Excellent Good Fair Poor Question Title * 8. FRONT DESKFriendly, helpful, answered questions Excellent Good Fair Poor Question Title * 9. Time spent in the waiting room Excellent Good Fair Poor Question Title * 10. Time spent in the exam room Excellent Good Fair Poor Question Title * 11. STAFFReturn calls, keep you up to date on test results, medications and referrals Excellent Good Fair Poor Question Title * 12. STAFF NURSESFriendly,helpful and answers questions Excellent Good Fair Poor Question Title * 13. PROVIDERListens, takes time, answers questions, provides advice on self-care and treatment options Excellent Good Fair Poor Question Title * 14. PAYMENTCollection of money/payment Excellent Good Fair Poor Question Title * 15. Facility: neat, clean comfort and safety Excellent Good Fair Poor N/A Question Title * 16. Confidentiality:Personal information kept private Excellent Good Fair Poor N/A Question Title * 17. Comments/Suggestions: Done