Patient Experience Feedback Question Title * 1. What type of visit were you here for today? Nursing Appointment Medical/Provider Appointment Behavioral health Appointment Sliding Fee Enrollment/Patient Assistance Program Other Question Title * 2. How satisfied were you with the amount of time our staff spent with you addressing your needs? Too short About the right length Too Long Other (please specify) Question Title * 3. How likely is it that you would recommend our clinic to a friend or colleague? Not at all likely Extremely likely 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Question Title * 4. Is there anything we could have done to improve your visit today? Yes No Next
