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

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

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

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

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

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

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

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

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

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

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

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* 12. What is your age?

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* 13. Your provider's name

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

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

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* 16. Additional Comments

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* 17. Your Name (Optional)

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