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* 1. You were seen by the following Nurse Practitioner:

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* 2. Was this your first visit to our clinic?

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* 3. Would you recommend this office to your friends and family?

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* 4. Once you arrived your wait time was:

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* 5. During your visit how often did the Nurse Practitioner treat you with courtesy and respect?

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* 6. During your visit how often did the Nurse Practitioner listen carefully to you?

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* 7. During this office visit how often did the Nurse Practitioner explain things in a way you could understand?

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* 8. The amount of time the Nurse Practitioner spent with me was:

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* 9. The staff was friendly and efficient.

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* 10. The explanation of test(s) and treatment by the staff was:

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* 11. I was given adequate discharge instructions.

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* 12. The cleanliness and comfort of this office was:

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* 13. What one thing could we do that would most improve your office experience?

Please take an Everyone Shines Here comment card to acknowledge
a staff member who deserves recognition.

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* 14. Date of visit (optional)

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* 15. Contact information (optional)

Thank you for taking the time to fill out our survey so that we may improve our services to our patients. Your suggestions are very important to us. If you have additional information or concerns please feel free to contact:

Physician Clinic Manager

816-629-6523
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