We would like to know how you feel about the services we provide in order to ensure we are meeting your needs.  Your responses are directly responsible for improving these services.  All responses will be kept confidential and anonymous.  Thank you for your time.

* Date of Visit

Date
/
/

* Please check "Yes" or "No" to the following questions/statements

  Yes No N/A
My call was answered within 3 rings.
The person who answered the call was courteous.
There was an appointment available within 24 hours or at a convenient time.
Waiting time in the reception area was reasonable.
Front office staff were courteous and helpful.
Staff that assisted me with insurance or program eligibility were helpful and friendly.
I was informed that the clinic offers medical, dental, optometry and mental health services. 
The back office staff have a courteous and helpful attitude.
My doctor gave me the respect and time I needed to express my concerns
I was given a visit summary today 
The clinic helps me to obtain specialty care for my eyes (optometry), teeth (dental), mental well being (behavioral health) and other areas of my health.
I feel my Care Team (my primary care provider, nurse, and medical assistant) cares about me as a person and not just as a patient.
I am satisfied with the care I received today from my Care team. including my primary care provider, nurse and medical assistant.
Was the facility clean?
Will you refer a friend or relative to the clinic in the future?

* Suggestions/comments:

* If you would like to be contacted, please provide your name and number below.

T