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