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Patient Satisfaction Survey

1.Date of Visit
Date / Time
2.Language
3.Department
4.Provider
5.Which age bracket do you fall into?
6.I was able to speak with a Call Center Agent within 0-5 minutes of calling in.
7.I was involved in decision-making about my own health and well-being .
8.I am confident I can get medical help from Ravenswood Family Health Center between appointments.
9.Overall, I was satisfied with my visit.
10.From the time you were checked in, how long did you wait until you were taken to exam room?
11.For today's visit, I made my appointment:
12.Does lack of transportation prevent you from seeking care?  
13.Do you need help with transportation to the clinic?
14.Do the clinic hours prevent you from seeking care?
15.What time do you prefer for you and your family? Choose all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning  8:00am - 12:00pm
Afternoon  1:00pm - 5:00pm
Evening 5:00pm - 7:00pm
16.Are you able to pay the discounted amount requested for care?
17.Does the discounted fee prevent you from seeking care?
18.Are there any comments you would like to make?