EMHC Quality Assurance 11 Questions Patient Satisfaction Survey

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* 1. Date of service:

Date

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* 2. Select the Clinic or the purpose for your visit that most applies ?

Behavioral Health

Dental

Diabetes Building

Elbowoods Memorial Health Center

Lab Only Visit

Mandaree

Optometry

Parshall

Pharmacy Visit

Public Health Clinic

Radiology/Ultrasound/CT scan

Twin Buttes

White Shield

Patient Referred Services PRC

Medical Records

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* 3. How likely is it that you would recommend Clinic to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

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* 4. How would you rate the cleanliness of our Clinic or Facility ?

Above average

Average

Below average

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* 5. How would you rate your overall quality of your Visit ?

Extremely professional

Very professional

Somewhat professional

Not so professional

Not at all professional

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* 6. How would you rate your experience with checking in for your Visit ?

Very easy

Easy

Neither easy nor difficult

Difficult

Very difficult

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* 7. Did the staff explain and provide clear answers to any of your questions ?

Extremely clear

Very clear

Somewhat clear

Not so clear

Not at all clear

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* 8. How would you rate our customer service ?

Extremely friendly

Very friendly

Somewhat friendly

Not so friendly

Not at all friendly

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* 9. How long have you been a patient at our facility?

Less than six months

Six months to a year

1 - 2 years

3 or more years

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* 10. How would rate our parking distance from the front entrance ?

Too short

About the right length

Too long

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* 11. Do you have any other comments, questions, or concerns? If would like us to contact you leave your name and number here. Thank you for your time.