* 1. Which clinic did you visit?

* 2. Date of visit

Please enter a valid date

* 3. Date of Birth

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* 4. Clinic & Staff

  Strongly disagree Somewhat disagree Neutral Somewhat agree Strongly agree
The lobby was clean and comfortable
The exam room was clean and comfortable
My wait time was within my expectations (If not, please indicate how long you waited in the comment section below)
The person at the front desk greeted me and helped me in a friendly manner
The clinic staff was polite, friendly and respectful of my needs

* 5. My Care

  Strongly Disagree Somewhat Disagree Neutral Somewhat Agree Strongly Agree N/A
The physician who treated me was courteous and respectful
Tests and procedures were explained to help me understand my care
My questions were fully answered
My pain issues were adequately addressed
Follow up instructions were clear

* 6. Overall Impression

  Extremely Unlikely Neutral Extremely Likely
How likely is it that you would recommend Alliance Urgent Care to a family member, friend or colleague?

* 7. What could we have done to make your experience better? What did we do well?