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* 1. Where was your last visit:

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* 2. Was this your first visit?

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* 3. Do you have a primary care physician that you see for regular check-ups?

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* 4. Tell us about your recent visit. How many minutes did you wait past your scheduled appointment time?

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* 5. How many minutes did you wait in the exam room before you were seen by a doctor?

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* 6. Please rate the services you received from our team of physicians and staff. Select the responses that best describes your experience.

  Poor Fair Good Very Good Excellent
When scheduling your appointment, how well did the scheduler take your needs and schedule into consideration
The level of courtesy and professionalism provided by the staff who registered you for the visit
Your confidence in the physician/practitioner that provided the care or service
The amount of time the physician/practitioner spent with you
The level of concern and respect the physician/practitioner expressed for your condition that brought you in for your visit
Explanations and information the physician/practitioner gave you about your problem or condition
Physicians’/practitioners’ efforts to include you in the decisions about your care
Likelihood of recommending the physician/practitioner to others
Overall hygiene of the staff to ensure your safety (washing hands, wearing protective gear as needed, sanitizing the exam room and equipment, etc.)
Ease of access to your health records, appointment schedule, and lab results online
In general, how would you rate your experience with our providers and facilities

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* 7. If you had to decide today about renewing your enrollment with our services, would you?

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* 8. Did you receive exceptional service?
Is there someone who provided extra care and attention to you during your visit?

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* 9. Please describe how they went above and beyond for you by sharing your story with us:

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* 10. Would you provide your permission to share this information with our staff?

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* 11. Would you provide your permission for us to share this information in our communication materials including our website, social media and literature?

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* 12. Anything else you would like us to know?

0 of 12 answered
 

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