Patient Satisfaction Survey

Question Title

1. Name

Question Title

2. Date of your most recent visit

Date / Time

Date

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3. Please indicate which clinic:

Buckhorn

Harlan

Leatherwood/Blackey

Owsley

Whitesburg

Pineville

Cumberland

Isom

School Based

Middlesboro

Question Title

4. What best describes you?

I am a first time patient of MCHC

I am an established patient of MCHC but I do not come for medical care on a regular basis

I am an established patient of MCHC and come for medical care on a frequent basis

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5. Do you consider MCHC your regular source of care?

Yes

No

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6. Were you seen by appointment or as a walk-in patient?

By appointment

Walk-in

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7. Which provider (the person who you saw for care) did you see on the date of this visit?