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1. Date of Visit

Date

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2. Language

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3. Department

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4. Provider

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5. Which age bracket do you fall into?

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6. I was able to speak with a Call Center Agent within 0-5 minutes of calling in.

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7. I was involved in decision-making about my own health and well-being .

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8. I am confident I can get medical help from Ravenswood Family Health Center between appointments.

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9. Overall, I was satisfied with my visit.

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10. From the time you were checked in, how long did you wait until you were taken to exam room?

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11. For today's visit, I made my appointment:

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12. Does lack of transportation prevent you from seeking care?  

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13. Do you need help with transportation to the clinic?

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14. Do the clinic hours prevent you from seeking care?

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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

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16. Are you able to pay the discounted amount requested for care?

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17. Does the discounted fee prevent you from seeking care?

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18. Are there any comments you would like to make?  

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