Activate Healthcare Patient Satisfaction Survey

1. Introduction

17% of survey complete.

Dear Patient: Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We'd like to know how you feel about our medical services, our physician and staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs.

This survey should take about 5 minutes of your time and your answers will remain anonymous. If you have any questions please contact us at surveyhelp@activatehealthcare.com. Thank you for your time.

Please answer the questions from the patient's perspective.

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1. What is your survey code?
If you are unsure, please refer to the paper survey you received from the clinic. Otherwise, please call the clinic for your code.

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2. What was the date of your visit?

Date:

Date

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3. Are you (the patient in this visit) the:

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4. What clinic did you visit?

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5. What is your gender?

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6. What is your age group?

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7. Was this your first visit to our clinic?

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8. What was the purpose of your visit?

Other (please specify)

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1. What is your survey code?If you are unsure, please refer to the paper survey you received from the clinic. Otherwise, please call the clinic for your code.

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2. What was the date of your visit?

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3. Are you (the patient in this visit) the:

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4. What clinic did you visit?

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5. What is your gender?

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6. What is your age group?

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7. Was this your first visit to our clinic?

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8. What was the purpose of your visit?

1. What is your survey code?
If you are unsure, please refer to the paper survey you received from the clinic. Otherwise, please call the clinic for your code.