What is your age? * _____________________

What is your Race/Ethnicity? Circle One:

Asian

Pacific Islander

Black/African American

American Indian/Alaska Native

White (Not Hispanic or Latino)

Hispanic or Latino (All Races)

Biracial

Multiracial

What is your sex? *

  1. Male
  2. Female
  3. Transgender

Who was your provider at today's visit? ________________________________

Ease of getting care: How do you rate the ability to get in to be seen?

Great______

Good_____

Ok_______

Fair______

Poor_____

Ease of getting care: Rate the hours the center is open?

Great______

Good_____

Ok_______

Fair______

Poor_____

Ease of getting care: Rate the convenience of the center's location.

Great______

Good_____

Ok_______

Fair______

Poor_____

Ease of getting care: Rate the degree to which you were informed about any delays by circling one answer

Great______

Good_____

Ok_______

Fair______

Poor_____

Ease of getting care: Appointments are offered within 24 hours of request.

Great______

Good_____

Ok_______

Fair______

Poor_____

Ease of getting care: Appointments are offered within 24 hours of request.

Great______

Good_____

Ok_______

Fair______

Poor_____

Rate your waiting time in waiting room

Great______

Good_____

Ok_______

Fair______

Poor_____

Rate your waiting time in exam room

Great______

Good_____

Ok_______

Fair______

Poor_____

Rate your time for waiting for test results

Great______

Good_____

Ok_______

Fair______

Poor_____

Staff listens to you

Great______

Good_____

Ok_______

Fair______

Poor_____

Staff takes enough time with you

Great______

Good_____

Ok_______

Fair______

Poor_____

Staff explanation of care or your condition with you

Great______

Good_____

Ok_______

Fair______

Poor_____

Staff - Degree to which provider talked with you using words you could understand

Great______

Good_____

Ok_______

Fair______

Poor_____

Nurses & Medical Assistants - Friendly & helpful to you

Great______

Good_____

Ok_______

Fair______

Poor_____

Nurses & Medical Assistants - You were provided a visit summary

Great______

Good_____

Ok_______

Fair______

Poor_____

Your visit summary was reviewed with you

Great______

Good_____

Ok_______

Fair______

Poor_____

Reception/Front Office: Are concerned for your privacy

Great______

Good_____

Ok_______

Fair______

Poor_____

Reception/Front Office: Rate Helpfulness of person who scheduled your appointment

Great______

Good_____

Ok_______

Fair______

Poor_____

Reception/Front Office: How helpful was the person who checked you in at the

Great______

Good_____

Ok_______

Fair______

Poor_____

Reception at front desk?/Front Office: How was the courtesy of the person who checked you out?

Great______

Good_____

Ok_______

Fair______

Poor_____

Payment: How was the explanation of charges/payment options?

Great______

Good_____

Ok_______

Fair______

Poor_____

Payment: How was the collection of payment/money handled?

Great______

Good_____

Ok_______

Fair______

Poor_____

Facility: How neat and clean was Facility:

Great______

Good_____

Ok_______

Fair______

Poor_____

How easy was it to find where to go in the building?

Great______

Good_____

Ok_______

Fair______

Poor_____

Facility: How was the comfort and noise level in the exam room?

Great______

Good_____

Ok_______

Fair______

Poor_____

How was the privacy in the exam room?

Great______

Good_____

Ok_______

Fair______

Poor_____

How well was the staff with protecting your safety (by washing hands or using sanitizer)?

Great______

Good_____

Ok_______

Fair______

Poor_____

What is the likelihood of you referring your friends and relatives to us?

Great______

Good_____

Ok_______

Fair______

Poor_____

Do you consider this practice your regular source of care? Yes__ or No____

Please take time to honestly tell us your answers freely about questions below and thanks in advance as your satisfaction matters to us.

What do you like best about this practice?

What do you like best about our center?

What do you like best about our center?

FINISH SURVEY AND SUBMIT _____