You are being invited to take part in this survey because you have recently had a visit at Pan Am Clinic.

Your responses to the questions on this survey will help us improve the care we provide.

The survey will take approximately five minutes to complete.

Participation in the survey is completely voluntary and all your responses to the survey questions will be kept confidential.

* 1. Appointment Date (please indicate the date of your visit in either the a.m. or p.m. sections)

a.m.
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p.m.
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* 2. Have you been to Pan Am Clinic before? (select one)

* 3. Why did you choose Pan Am Clinic as your health care provider for your most recent visit?

* 4. While at Pan Am Clinic, which services did you utilize during your visit?

* 5. On a scale of Poor to Excellent, how would you rate the following?

  Poor Fair Good Very good Excellent
The length of time you had to wait in the reception/waiting area.
Your overall experience with our reception staff.
The length of time you had to wait in the examination room before you spoke with the health care provider about the reason for your visit.

* 6. Thinking about the MAIN health care provider you spoke with during the visit, on a scale of Poor to Excellent, how would you rate this person on the following?

  Poor Fair Good Very good Excellent
They listened to your concerns.
They explained things in a way that was easy to understand.
They were sensitive to your needs and preferences.
They gave you clear instructions about what you need to do after your visit.
They gave you an opportunity to ask questions about recommended treatment.
They involved you in decisions about your care as much as you wanted.
Your overall experience speaking with the health care provider about the reason for your visit.

* 7. Thinking about your most recent visit, on a scale of Poor to Excellent, how would you rate the following?

  Poor Fair Good Very good Excellent
The overall cleanliness of the office/clinic.
The overall physical comfort of the office/clinic.
Your ease of locating your desired department.
Your confidence in the doctor/health care provider(s) you saw during the visit.
Your confidence that your health information was treated with the level of privacy you expect.
Your overall experience with the visit you had with us.

* 8. Overall, did you feel you were treated with respect and dignity while you were in the Pan Am Clinic?

* 9. Would you recommend our services to your family or friends?  Check ONE only.

* 10. Thinking of your overall experience with our office/clinic, what are two things we are doing particularly well?

* 11. Thinking of your overall experience with our office/clinic, what are two things that could be improved?

* 12. Using any number from 0 - 10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate your most recent experience at Pan Am Clinic? (Slide the bar to choose your number)

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i We adjusted the number you entered based on the slider’s scale.

* 13. Is there any additional information or feedback you would like to share with us that could help us improve the way we provide care?

We thank you for taking the time to participate in this survey and provide us with your valuable feedback.
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