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1. Tell us about your visit

Date

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2. Name of Provider Seen:

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3. Specialty/Department visited:

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4. Is there anyone that you would like to recognize for excellent care or service?

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5. How would you rate how easy it was to schedule your appointment?

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6. How would you rate the friendliness & helpfulness of the patient registration staff upon arrival?

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7. How would you rate how easy it was to understand your provider's explanation of things?

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8. How would you rate the professionalism & courtesy of the clinical staff?

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9. How would you rate the overall cleanliness of our facility?

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10. If you have received an outside referral in the past, How would you rate your experience with PRC?

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11. How would rate your satisfaction with the care you received today?

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12. What did like best?

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13. What can we improve?

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