1. AfterOurs Visit

* 1. Which AfterOurs location did you visit?

* 2. What date did you visit AfterOurs?

* 3. At what time of day was your visit?

* 4. How were you referred to AfterOurs?

* 5. If you were referred by another healthcare provider, please indicate who:

* 6. Was this your first visit to our AfterOurs?

* 7. Do you have health insurance?

* 8. Which healthcare plan (insurance company) are you covered by?

* 9. Please rate the following aspects of your visit at AfterOurs Urgent Care.

  Strongly Agree Agree Satisfactory Disagree Strongly Disagree N/A
Office hours are convenient for me.
Office is easy to find.
The parking is adequate.
Building and office are clean and attractive.
Receptionist greeted me in a friendly manner.
Staff was helpful regarding my insurance coverage and applicable co-payments.
Reception area was comfortable and neat.
My wait time was acceptable.
The exam room was clean and well organized.
The clinical staff was courteous and helpful.
The physician was knowledgeable and courteous.
I received post visit information about my labs and/or x-rays
The procedures, treatment or tests were thoroughly explained and my questions were answered.
I received instructions on how to care for my condition.
I will return to the practice for future medical care.
I will recommend this practice to family and friends.

* 10. I prefer to receive health care services during my non-business hours.

* 11. Can we have your permission to post your comments on our website or promotional materials? No identifying information will be used - only your comments.

* 12. Please enter your information below if you would like us to contact you.

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