It is our goal to give you the best possible medical care. To do so, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we can improve. Your comments will be strictly confidential. Thank you!

By completing this survey, you will be entered into a random drawing for a $25 MasterCard gift card!!

* 1. Date of Visit

* 2. Your Provider's Name

* 3. This visit was:

* 4. Were you treated through the Urgent Care Clinic?

* 5. Why did you choose this office for your medical treatment?

* 6. Please describe your initial telephone call:

* 7. If you were placed on hold, was this a reasonable amount of time to be on hold?

* 8. How long did it take you to get in for your intial appointment?

* 9. After you arrived at the clinic, was the time that you had to wait to see your provider acceptable to you?

* 10. Please rate our practice in terms of:

  Excellent Very Good Good Fair Poor N/A
The person who answered your call
How you were treated when you arrived at the reception desk
The nurse/assistant that took care of you
The amount of time the provider spent with you
The comfort of the waiting room
Your ability to contact us after hours
Your check-out experience
The provider's interest in your problem
The provider's explanation of your illness/injury and treatment
The helpfulness of the individual helping with billing and/or insurance
The satisfaction of the medical treatment you received
The ease of use of the automated telephone system
Your experience with any x-ray procedures
Your experience with any MRI procedures
The patient education material provided
The explanation of your options, cost, fitting of Durable Medical Equipment (such as braces or slings) provided
Notification from staff if the provider was running behind
Test results reported in a reasonable amount of time
Adequate assistance in completion of any needed forms
What is your overall rating of our practice?

* 11. Please give us the names (if known) of:

* 12. Which hospital do you prefer?

* 13. Would you refer a family member or friend to our office?

* 14. What did you like best about your visit?

* 15. What did you like least about your visit? How can we improve?

* 16. Additional Comments:

* 17. May we use your patient survey as a testimonial in our marketing?

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