1.The last time you were sick or had a health problem, were you able to obtain an appointment on the DATE you requested?

Yes

No

2.The last time you had an urgent need (did not go to the ER, but needed care within 24 hours), were you offered a same day, or next day appointment?

Yes

No

3.When you see your physician or a nurse practitioner, how often do they, or someone else in the clinic, involve you as much as you want to be involved in the decisions about your care and treatment?

Always

Often

Sometimes

Rarely

Never

N/A

4.Do you feel comfortable and welcome at this clinic?

Always

Often

Sometimes

Rarely

Never

N/A

5.Check all that apply:

the staff are polite and welcoming

the lobby is tidy and welcoming

check in was smooth and efficient

6.When you book an appointment online, do you feel there is enough choices to accommodate your needs?

Always

Often

Sometimes

Rarely

Never

N/A

7.When you visit the clinic, are the waiting room times satisfactory?

Yes

No