* 1. What was the date of your visit?

* 2. Which provider did you see?

* 3. Was your appointment scheduled in a timely manner?

* 4. When you arrived did your appointment occur:

* 5. On a scale from 1 to 5 with 1 being “Poor” and 5 being “Excellent”, how would you rate:

  1 2 3 4 5
Ease of check-in
Front desk staff
Medical staff
Provider

* 6. Would you recommend our office to friends or family?

* 7. Comments:

* 8. Name (Optional):

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