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Patient/Client Satisfaction Form
We Want to Hear from You!
Instructions:
Please provide your immediate feedback about your recent visit to help us improve our services. This form is quick to complete, and your responses will remain anonymous.
*
1.
Choose your location seen at today.
(Required.)
Levelland
Lamesa
Big Spring
*
2.
Choose department seen at today.
(Required.)
Medical
Dental
Behavioral Health
Pharmacy
Laboratory
Food Bank
Other (please specify)
*
3.
Choose provider seen today.
(Required.)
Amy Elliott, FNP
Beatriz Garza, FNP
Delanie McElroy, FNP
Dolly Barter, FNP
Jeanette Hastings, FNP
Jody Pfeuffer, DMD
Katrina Petrowski, FNP
Kristy Acosta, MD
Lance Tolbert, LPC-S
Petros Chapanos, MD
Rachel Eagan, LPC-S
Robbie Tutunjian, FNP
Shima Setork, DMD
Susan Lance, FNP
Vicky Quilantan, FNP
Other (please specify)
4.
Was our staff friendly and welcoming?
Yes
No
5.
Does this clinic meet your health care needs?
Yes
No
6.
How long did you wait in the
LOBBY
before being called back to an exam room?
Less than 15 Minutes
15 to 30 Minutes
30 to 60 Minutes
Over 1 Hour
7.
How long did you wait in the
EXAM ROOM
before the provider came in?
Less than 15 Minutes
15 to 30 Minutes
30 to 60 Minutes
Over 1 Hour
8.
What would you rate your overall visit experience (0-10)?
0
10 (Best)
Clear
9.
Please list below any suggestions for how we can improve your experience.
