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Give Us You Feedback
1.
Tell us about your visit
Date of Visit:
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
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29
30
2.
Name of Provider Seen:
3.
Specialty/Department visited:
4.
Is there anyone that you would like to recognize for excellent care or service?
5.
How would you rate how easy it was to schedule your appointment?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
Comments:
6.
How would you rate the friendliness & helpfulness of the patient registration staff upon arrival?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
Comments:
7.
How would you rate how easy it was to understand your provider's explanation of things?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
Comments:
8.
How would you rate the professionalism & courtesy of the clinical staff?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
comments:
9.
How would you rate the overall cleanliness of our facility?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
comments:
10.
If you have received an outside referral in the past, How would you rate your experience with PRC?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
comments:
11.
How would rate your satisfaction with the care you received today?
Poor
1 star
2 stars
3 stars
4 stars
Excellent
5 stars
comments:
12.
What did like best?
13.
What can we improve?
