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Summerville Survey
*
1.
Please select your provider
(Required.)
Brittany O'Toole, FNP
2.
Do you participate in the sliding scale fee discount plan?
Yes
No
3.
If you do participate in the sliding scale plan, do you find your sliding scale fees:
Affordable
Not affordable
Not applicable
I do not have sliding scale
If yes, please explain why.
4.
Insurance
Yes
No
5.
Age
0-17
18-35
36-53
54-71
72+
Please select how well you think we are doing.
6.
EASE OF GETTING CARE
Scheduling, hours and location
Excellent
Good
Fair
Poor
7.
Scheduling: Friendly, helpful, answered questions.
Excellent
Good
Fair
Poor
8.
FRONT DESK
Friendly, helpful, answered questions
Excellent
Good
Fair
Poor
9.
Time spent in the waiting room
Excellent
Good
Fair
Poor
10.
Time spent in the exam room
Excellent
Good
Fair
Poor
11.
STAFF
Return calls, keep you up to date on test results, medications and referrals
Excellent
Good
Fair
Poor
12.
STAFF NURSES
Friendly,helpful and answers questions
Excellent
Good
Fair
Poor
13.
PROVIDER
Listens, takes time, answers questions, provides advice on self-care and treatment options
Excellent
Good
Fair
Poor
14.
PAYMENT
Collection of money/payment
Excellent
Good
Fair
Poor
15.
Facility: neat, clean comfort and safety
Excellent
Good
Fair
Poor
N/A
16.
Confidentiality:Personal information kept private
Excellent
Good
Fair
Poor
N/A
17.
Comments/Suggestions:
18.
If you were not happy with your office visit and would like to speak to someone about your experience, please enter in your name and number.
19.
Do you use the patient portal?
Yes
No
I don't know what the patient portal is
20.
If you do not to use the patient portal, please tell us why:
You would rather speak to someone on the phone
You do not have a smart phone or computer to access the patient portal
Not interested in using it
Other
21.
If you would like help using the patient portal, please leave your name and number and we will reach out to you to assist.