We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. We will use your responses to improve our services. All responses will be kept confidential and anonymous. Thank you for your time.

Question Title

* 1. Please indicate that location of your visit:

Question Title

* 2. Convenience of location for you?

Question Title

* 3. Convenience of hours of operation?

Question Title

* 4. How easy was it to schedule a visit with us?

Question Title

* 5. Treatment of confidential information by staff was:

Question Title

* 6. Please rate the cleanliness of your exam room

Question Title

* 7. Length of wait time?

Question Title

* 8. How would you rate the way your financial arrangements were handled?

Question Title

* 9. Did staff follow appropriate hand washing guidelines?

Question Title

* 10. Did your provider have a good understanding of your medical history?

Question Title

* 11. Did your provider listen to you carefully?

Question Title

* 12. Did the provider talk with you about specific goals for your health?

Question Title

* 13. How would you rate the courtesy of our staff?

Question Title

* 14. Did the provider explain what to do if your condition gets worse?

Question Title

* 15. Would you recommend this health center to others?

Question Title

* 16. Please indicate the name of the provider you saw during your visit today.

Question Title

* 17. Please indicate the following for the person seen by the provider today:

Question Title

* 18. Please indicate your age range:

Question Title

* 19. How was your visit paid for?

Question Title

* 20. Which Quarter of the year does the indicated data represent?

Question Title

* 21. Did registration staff ask for updated information (Photo ID, insurance, address, etc.)?

Question Title

* 22. Was the registration staff courteous?

Question Title

* 23. Please use the space below to address any questions, comments or concerns with your visit. If you would like us to follow up, please include your contact information.

T