* 1. The check-in staff was welcoming, friendly and helpful.

* 2. If you used the Kiosk to check in please tell us what you thought about the process.

* 3. How do you feel about the amount of time it took you to get an appointment?

* 4. The length of time you spent waiting in the office

* 5. The amount of time spent with the provider you saw

* 6. The personal manner (courtesy, respect, sensitivity, friendliness) of the provider you saw

* 7. The provider's sensitivity to your needs and/or concerns

* 8. Your satisfaction with how well this office communicates with other providers involved in your care

* 9. Your feeling about the overall quality of this visit

* 10. If you could go anywhere to get healthcare, would you choose this practice or prefer to go somewhere else?

* 11. Would you recommend this practice to your friends, family and peers?

* 12. What is your age?

* 13. Your provider's name

* 14. How did you hear about Coastal Women's Healthcare?

* 15. Is Coastal Women's Healthcare your sole provider for medical care?

* 16. Additional Comments

* 17. Your Name (Optional)

T