Uncompahgre Medical Center Survey

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* 1. You have recently been seen at UMC for a?

Medical Appointment

Dental Appointment

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* 2. Was this your first visit with us?

Yes

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* 3. What provider did you see today?

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* 4. Do you have insurance?

Yes

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* 5. If No, were you made aware of our Sliding Fee Scale?

Yes

N/A

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* 6. Was the information easy to understand and easily accessible?

Yes

If no, please explain:

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* 7. Have you ever delayed care or postponed a visit to UMC due to the inability to pay the nominal fee(copay)?

Yes

N/A

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* 8. In the past 6 months... How often have you been able to see your health care team when you wanted to?

Always

Usually

Sometimes

Rarely

Never

n/a

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* 9. In the past 6 months...How often has the staff treated you with courtesy and respect?

Always

Usually

Sometimes

Rarely

Never

n/a

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* 10. In the past 6 months... Has anyone talked to your about how you can improve your health in the future?

Always

Usually

Sometimes

Rarely

Never

n/a

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* 11. In the past 6 months... How often do you feel that everyone involved in your care worked well together?

Always

Usually

Sometimes

Rarely

Never

n/a

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* 12. In the past 6 months... How often do you feel your provider has listened to you?

Always

Usually

Sometimes

Rarely

Never

n/a

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* 13. Based on your care in the past 6 months... How likely are you to recommend us to family and friends?

Highly likely

Likely

Somewhat likely

Unlikely

Highly unlikely

Other (please specify)

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* 14. How did you hear about us or the services we provide?

Newspaper

Radio

Facebook

Our Website

Patient/Staff Member

Other (please specify)

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* 15. Thinking about your most recent appointment, how would you rate... Respect of your privacy and confidentiality

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Other (please specify)

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* 16. Thinking about your most recent appointment, how would you rate... the cleanliness and up keep of the clinic

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Other (please specify)

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* 17. Thinking about your most recent appointment... What was your overall rating of your experience at the clinic?

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Very Dissatisfied

Dissatisfied

Satisfied

Very Satisfied

Other (please specify)

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* 18. How could we improve?

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* 19. What do we do well?

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* 20. Would you like to recognize someone who exceeded your expectations?

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* 21. Can UMC reach out to you regarding your feedback?

Yes

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* 22. If yes, please enter your name and contact information.

Name

Email Address

Phone Number

Uncompahgre Medical Center

Patient Satisfaction Survey

Question Title

* 1. You have recently been seen at UMC for a?

Question Title

* 2. Was this your first visit with us?

Question Title

* 3. What provider did you see today?

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* 4. Do you have insurance?

Question Title

* 5. If No, were you made aware of our Sliding Fee Scale?

Question Title

* 6. Was the information easy to understand and easily accessible?

Question Title

* 7. Have you ever delayed care or postponed a visit to UMC due to the inability to pay the nominal fee(copay)?

Question Title

* 8. In the past 6 months... How often have you been able to see your health care team when you wanted to?

Question Title

* 9. In the past 6 months...How often has the staff treated you with courtesy and respect?

Question Title

* 10. In the past 6 months... Has anyone talked to your about how you can improve your health in the future?

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* 11. In the past 6 months... How often do you feel that everyone involved in your care worked well together?

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* 12. In the past 6 months... How often do you feel your provider has listened to you?

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* 13. Based on your care in the past 6 months... How likely are you to recommend us to family and friends?

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* 14. How did you hear about us or the services we provide?

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* 15. Thinking about your most recent appointment, how would you rate... Respect of your privacy and confidentiality

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* 16. Thinking about your most recent appointment, how would you rate... the cleanliness and up keep of the clinic

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* 17. Thinking about your most recent appointment... What was your overall rating of your experience at the clinic?

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* 18. How could we improve?

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* 19. What do we do well?

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* 20. Would you like to recognize someone who exceeded your expectations?

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* 21. Can UMC reach out to you regarding your feedback?

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* 22. If yes, please enter your name and contact information.