External Referral Feedback Question Title * 1. Specialty Question Title * 2. Doctor/Specialist's Name Question Title * 3. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Doctor or Specialist. 1 2 3 4 5 n/a Question Title * 4. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Other clinical staff (e.g. nurse). 1 2 3 4 5 n/a Question Title * 5. In terms of sensitivity to your sexual orientation or gender identity, please rate your experience from 1 (lowest) to 5 (highest) with... Front desk/administrative staff. 1 2 3 4 5 n/a Question Title * 6. Overall how satisfied were you with the quality of the doctor’s care? 1 being not satisfied and 5 being extremely satisfied. 1 2 3 4 5 n/a Question Title * 7. Please provide some details about your experience. Question Title * 8. Would you recommend this specialist to a friend? yes no Question Title * 9. What is your sexual orientation Lesbian Gay Bisexual Heterosexual Other (please specify) Question Title * 10. Do you identify as transgender or gender non-conforming? Yes No Other (please specify) Done