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* 2. What is your overall satisfaction with this Doctor/Provider?

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* 3. How would you rate your ability to obtain an appointment as soon as needed for a regular office visit or a physical exam?

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* 4. How would you rate your wait time from when you arrive at the office until seen by your Doctor/Provider?

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* 5. How would you rate of the respect and courtesy of the staff?

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* 6. How would you rate the respect and courtesy of your Doctor/Provider?

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* 7. How would you rate the amount of time your Doctor/Provider spends with you at your office visit?

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* 8. How would you rate follow up in a timely manner by the Doctor/Office Staff regarding test results or questions?

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* 9. How would you rate your ability to contact the Doctor on call when the office is closed?

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* 10. What is the likelihood you would refer this Doctor/ Provider to friends/family?

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* 11. What languages do you understand fluently? Please choose all that apply.

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* 12. What is your gender.

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* 13. What is your age

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* 14. Which Race/Ethnicity best describes you?

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