* 1. Is this your first visit?

* 2. Which Sunrise clinic did you go to for care?

* 3. Who is your provider? (example: Doctor, Physician Assistant, Dentist)

* 4. How did you get to the clinic for your visit?

* 5. Do you have internet access at home?

* 6. Have you registered to activate your Patient Portal account? 

* 7. If so, which of the following tools have you used on your Patient Portal account?

* 8. Please rate the services you received from us

  Excellent Good Fair Poor N/A
The length of time you spent on the phone making an appointment.
The length of time between the day you made the appointment and the day of your appointment.
The length of time you spent in our clinic.
Our staff is friendly and respectful at the front desk (phones, check in, records).
Our staff is friendly and respectful in billing and collectibles.
Our staff is friendly and respectful in the lab.
Our staff is friendly and respectful in pharmacy.
Our staff is friendly and respectful in the back office (clinicians and nursing staff).
Our staff is friendly and respectful in WIC.
Your provider explains your treatment and answers your questions.
Your provider shows interest in you as a patient.
Your provider spends adequate time with you.
Your privacy and confidentiality are respected.
Your financial situation is considered.
The clinic is clean and well kept.

* 9. In the past 12 months, how many days did you usually have to wait for an appointment when you NEEDED CARE RIGHT AWAY?

* 10. In the past 12 months, how often did your provider explain things in a way that was easy to understand?

* 11. In the past 12 months, did anyone in the provider's office talk with you about specific goals for your health?

* 12. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you try to make any appointments to see a specialist?

* 13. In the past 12 months, how often did your provider seem informed and up to date about the care you received from specialists?

* 14. How can we improve?

* 15. What do we do well?

* 16. Would you like to recognize and employee who exceeded your expectations?

* 17. Would you recommend Sunrise Community Health to a friend or family member?

* 18. Would you like us to contact you to follow up on your concerns or questions? If so, please leave your contact information below (your name and phone or email)

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