CUSTOMER SATISFACTION SURVEY
All survey responses are 100% confidential

* 1. Which Health Center site are you filling this survey out for?

* 2. How easy was it to make your appointment?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

* 3. Were the Total Health Care forms easy to understand?

Yes

* 4. Was the receptionist/front desk pleasant and helpful?

Extremely pleasant and helpful

Helpful and pleasant

Somewhat helpful and pleasant

Not helpful and/or pleasant

Extremely unhelpful and/or unpleasant

* 5. Was the parking convenient?

Very convenient

Convenient

Neutral

Difficult

Very difficult

* 6. Did you find the treatment area welcoming?

Very welcoming

Welcoming

Neither welcoming nor unwelcoming

Unwelcoming

Very unwelcoming

* 7. Did the providers treat you with respect and empathy during your visit?

Extremely respectful

Respectful

Somewhat respectful

Not so respectful

Not at all respectful

* 8. Did we manage your account appropriately?

Extremely well handled

Well handled

Neither

Not well handled

Account handled horribly

* 9. Did a Total Health Care staff member explain the Sliding Fee Scale to you?

Yes

* 10. Did you understand what was explained to you or do you understand the amount of payment for your visit?

Yes

* 11. Is the following statement True or False?

Is the Sliding Fee Scale you were assessed for based on the total number of people in your household (yourself, spouse and children under 18) and the total household income.

Yes

I don't know

* 12. How much do you pay for your visit?

Less than $25

$25

$26.24

$52.48

$78.71

$104.95

$131.19