* 1. Did the Receptionist greet you with respect and kindness?

* 2. Did the Medical Assistant listen to you and was attentive to your needs?

* 3. Did the Provider have good bedside manners?

* 4. Did you understand your diagnosis, treatment and follow-up?

* 5. Please rate your overall satisfaction with your visit.

* 6. Please rate the cleanliness of our facility.

* 7. Would you recommend Hometown to friends and family members?

* 8. How would you compare Hometown to other urgent cares you have visited?

* 9. Please suggest one thing we could change to make your next visit better.

* 10. Visit ID

* 11. Visit Date

MM/DD/YYYY
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* 13. Optional contact Information: Please provide your name, phone or email address.

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