* I am

* How did you hear about us?

* How would you rate our 'Amenities'

  Worst Bad Okay Good Excellent
The process of scheduling your appointment
The location of the clinic
The greeting you received from staff today
The cleanliness of the clinic
The comfort of the waiting room
The comfort of the exam room
The condition of the building
The ease of moving around the clinic
The private places to talk with clinic staff

* How would you rate the 'Waiting Time' (for the visit to the doctor)

* How would you rate our 'Medical Expertise'

  Worst Bad Okay Good Excellent
The knowledge of the doctor
The skill of the doctor
The knowledge and skill of other staff member
Receiving the service(s) you needed or wanted
Staff maintaining your confidentiality

* How would you rate our 'Efficiency and Systems'

  Worst Bad Okay Good Excellent
The quickness of the staff
The readiness of the staff and clinic for your visit
Time spent waiting for the doctor
Length of time spent with the doctor

* How would you rate 'People Skills'

  Worst Bad Okay Good Excellent
The show of concern and care from the staff
Staff willingness to listen to or talk with you
Staff meeting your emotional needs
The friendliness and helpfulness of the staff

* How would you rate our telephone systems

  Worst Bad Okay Good Excellent
Waiting time for the call (to reach the operator/staff)
Availability of the telephone lines

* Would you recommend our clinic to your family or friends

* General Comments/Suggestions, if any

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