Community Health Systems: Patient Satisfaction Survey

Please tell us how you feel about the services we provide in order to ensure we are meeting your needs. Your responses are
directly responsible for improving these services.

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* Which of our health centers did you visit?

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* Which department did you visit?

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* Date of Visit

Date

Date

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* Please check "Yes" or "No" to the following questions/statements

	Yes	No	N/A
My call was answered within 3 rings.	My call was answered within 3 rings. Yes	My call was answered within 3 rings. No	My call was answered within 3 rings. N/A
The staff that I encountered throughout the clinic was helpful and courteous.	The staff that I encountered throughout the clinic was helpful and courteous. Yes	The staff that I encountered throughout the clinic was helpful and courteous. No	The staff that I encountered throughout the clinic was helpful and courteous. N/A
There was an appointment available within 24 hours, or at a convenient time.	There was an appointment available within 24 hours, or at a convenient time. Yes	There was an appointment available within 24 hours, or at a convenient time. No	There was an appointment available within 24 hours, or at a convenient time. N/A
Waiting time in the reception area was reasonable.	Waiting time in the reception area was reasonable. Yes	Waiting time in the reception area was reasonable. No	Waiting time in the reception area was reasonable. N/A
My doctor gave me the respect and time I needed to express my concerns	My doctor gave me the respect and time I needed to express my concerns Yes	My doctor gave me the respect and time I needed to express my concerns No	My doctor gave me the respect and time I needed to express my concerns N/A
I was given a copy of my patient plan after my visit today.	I was given a copy of my patient plan after my visit today. Yes	I was given a copy of my patient plan after my visit today. No	I was given a copy of my patient plan after my visit today. N/A
The clinic helps me to obtain specialty care for my eyes (Optometry), teeth (Dental), mental well-being (Behavioral Health).	The clinic helps me to obtain specialty care for my eyes (Optometry), teeth (Dental), mental well-being (Behavioral Health). Yes	The clinic helps me to obtain specialty care for my eyes (Optometry), teeth (Dental), mental well-being (Behavioral Health). No	The clinic helps me to obtain specialty care for my eyes (Optometry), teeth (Dental), mental well-being (Behavioral Health). N/A
I feel my Care Team (my provider, nurse, and medical assistants) cares about me.	I feel my Care Team (my provider, nurse, and medical assistants) cares about me. Yes	I feel my Care Team (my provider, nurse, and medical assistants) cares about me. No	I feel my Care Team (my provider, nurse, and medical assistants) cares about me. N/A
I am satisfied with the care I received today from my Care Team.	I am satisfied with the care I received today from my Care Team. Yes	I am satisfied with the care I received today from my Care Team. No	I am satisfied with the care I received today from my Care Team. N/A
I will refer a friend or relative to the clinic in the future.	I will refer a friend or relative to the clinic in the future. Yes	I will refer a friend or relative to the clinic in the future. No	I will refer a friend or relative to the clinic in the future. N/A

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* Suggestions/comments:

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* If you would like to be contacted, please provide your name and number below.

Name:

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