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Uncompahgre Medical Center
Patient Satisfaction Survey
Your feedback is important to us.
OK
1.
You have recently been seen at UMC for a?
Medical Appointment
Dental Appointment
2.
Was this your first visit with us?
Yes
No
3.
What provider did you see today?
4.
Do you have insurance?
Yes
No
5.
If No, were you made aware of our Sliding Fee Scale?
Yes
No
N/A
6.
Was the information easy to understand and easily accessible?
Yes
No
If no, please explain:
7.
Have you ever delayed care or postponed a visit to UMC due to the inability to pay the nominal fee(copay)?
Yes
No
N/A
8.
In the past 6 months...
How often have you been able to see your health care team when you wanted to?
Always
Usually
Sometimes
Rarely
Never
n/a
9.
In the past 6 months...
How often has the staff treated you with courtesy and respect?
Always
Usually
Sometimes
Rarely
Never
n/a
10.
In the past 6 months...
Has anyone talked to your about how you can improve your health in the future?
Always
Usually
Sometimes
Rarely
Never
n/a
11.
In the past 6 months...
How often do you feel that everyone involved in your care worked well together?
Always
Usually
Sometimes
Rarely
Never
n/a
12.
In the past 6 months...
How often do you feel your provider has listened to you?
Always
Usually
Sometimes
Rarely
Never
n/a
13.
Based on your care in the past 6 months...
How likely are you to recommend us to family and friends?
Highly likely
Likely
Somewhat likely
Unlikely
Highly unlikely
Other (please specify)
14.
How did you hear about us or the services we provide?
Newspaper
Radio
Facebook
Our Website
Patient/Staff Member
Other (please specify)
15.
Thinking about your most recent appointment, how would you rate...
Respect of your privacy and confidentiality
Very Dissatisfied
1 star
Dissatisfied
2 stars
OK
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
Other (please specify)
16.
Thinking about your most recent appointment, how would you rate...
the cleanliness and up keep of the clinic
Very Dissatisfied
1 star
Dissatisfied
2 stars
OK
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
Other (please specify)
17.
Thinking about your most recent appointment...
What was your overall rating of your experience at the clinic?
Very Dissatisfied
1 star
Dissatisfied
2 stars
OK
3 stars
Satisfied
4 stars
Very Satisfied
5 stars
Other (please specify)
18.
How could we improve?
19.
What do we do well?
20.
Would you like to recognize someone who exceeded your expectations?
21.
Can UMC reach out to you regarding your feedback?
Yes
No
22.
If yes, please enter your name and contact information.
Name
Email Address
Phone Number
Current Progress,
0 of 22 answered
