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Please tell us how you feel about our services and staff.  Your responses help us to make improvements.  This survey is anonymous.  Thank you for your time.

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* 1. Date of appointment:

Date

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* 2. Which location were you seen at today?

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* 3. What is your Gender?

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* 4. What is your age?

Please rate how well we are doing in the following areas:

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* 5. Convenience of clinic location

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* 6. Courtesy of front desk staff

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* 7. Clearly explained registration process

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* 8. Answered your questions

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* 9. Courtesy of provider

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* 10. Provider listened to you

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* 11. Provider took enough time with you

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* 12. Provider clearly explained what you wanted to know

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* 13. Provider clearly explained medication

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* 14. Courtesy of nurse

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* 15. Nurse clearly explained what you want to know

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* 16. Explained today's charges

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* 17. How do you feel about the cost of your visit today

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* 18. Staff respected privacy

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* 19. If you received a contraceptive method today, is it what you wanted?

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* 20. How did you hear about us?

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* 21. What do you like best about our clinic?

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* 22. What do you like least about our clinic?

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* 23. What could we have done to make your visit better today?

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* 24. Would you recommend us to friends/family?

Thank you for completing our survey!
Please contact the Wyoming Health Council with any additional comments or concerns at:
307-439-2033 or gwilson@wyhc.org
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