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* 1. I recently had an appointment at the following office:

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* 2. I saw the following provider at that appointment:

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* 3. I heard about GAP from...

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* 4. I would recommend GAP to a friend, family member, or colleague.

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* 5. At my appointment, the providers and staff listened to, respected, and took the necessary time to answer my questions.

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* 6. I feel that I was given enough information at my appointment to appropriately manage my health.

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* 7. I feel that I am able to receive routine, urgent and after-hours care from GAP when I need it.

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* 8. In the past when blood work, procedures or other tests were ordered for me, GAP gave me those results within 3 business days.

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* 9. In the past when I have called GAP with a question, I received a response within one business day.

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* 10. I feel that GAP sufficiently communicates my care plan with my primary care physician.

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* 11. The following obstacles might keep me from receiving proper care with GAP:

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* 12. Use this space to provide any comments or feedback regarding your experience. If you have questions or would like to discuss your feedback with management, please contact us at (336) 448-2427.

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