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

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

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

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

* 5. Was the parking convenient?

* 6. Did you find the treatment area welcoming?

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

* 8. Did we manage your account appropriately?

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

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

* 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.

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

* 13. Was the amount that you paid for the visit reasonable?

* 14. Do you have any other comments, questions, or concerns?