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BMRHC Patient Survey
We would like to know how you feel about the services we provide so we can ensure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept anonymous. Thank you for your time.
When completing this survey online it is possible that any information entered herein may not be secure. Information entered may be intercepted by someone other than yourself or Boston Mountain Rural Health Center, Inc. By agreeing to use the online survey below you acknowledge, this information may not be private. You also acknowledge this form is optional and may be completed on paper if so desired. *
Required
Age: *
Your answer
Sex: *
Race/Ethnicity: *
Required
Do you have health insurance?: *
Location where you received care: *
Type of care received: *
Ease of getting care:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Ability to get in to be seen: *
Poor
Outstanding
Hours BMRHC is open: *
Poor
Outstanding
Convenience of BMRHC's location: *
Poor
Outstanding
Prompt return of calls: *
Poor
Outstanding
Waiting:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Time in waiting room: *
Poor
Outstanding
Time in exam room: *
Poor
Outstanding
Waiting for test to be performed: *
Poor
Outstanding
Waiting for test results: *
Poor
Outstanding
Staff: Physician, Dentist, Hygienist, Advanced Nurse Practitioner:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Listens to you: *
Poor
Outstanding
Takes enough time with you: *
Poor
Outstanding
Explains what you want to know: *
Poor
Outstanding
Gives you good advice and treatment: *
Poor
Outstanding
Provides whole person care by providing advice, assistance, and support for making changes in my health care habits and making health care decisions: *
Poor
Outstanding
Coordinating services for specialists, medications, lab tests, or imaging: *
Poor
Outstanding
Staff: Nurses & Medical/Dental Assts.
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Friendly and helpful to you: *
Poor
Outstanding
Answer your questions: *
Poor
Outstanding
Other Staff: Patient Service Representative, Billing, Other:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Friendly and helpful to you: *
Poor
Outstanding
Answer your questions: *
Poor
Outstanding
Payment:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Do you think your nominal fee is reasonable: *
Poor
Outstanding
Explanation of charges and discount fees: *
Poor
Outstanding
Explanation of insurance co-pays or requirements: *
Poor
Outstanding
Collection of payment/money: *
Poor
Outstanding
Facility:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Ease of finding where to go: *
Poor
Outstanding
Comfort and safety while waiting: *
Poor
Outstanding
Privacy: *
Poor
Outstanding
Neat and clean treatment and waiting rooms: *
Poor
Outstanding
Confidentiality:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
Keeping your personal information private: *
Poor
Outstanding
Other:
Please select the appropriate response that corresponds with how you feel about each of the following areas using the following rating scale:

1- Poor 2- Fair 3- Neutral 4- Good 5- Outstanding
The likelihood of referring your friends and family to us: *
Poor
Outstanding
Additional Questions:
Do you consider BMRHC your regular source of care?: *
Required
What do you like best about BMRHC?
Your answer
What do you like least about BMRHC?
Your answer
What can we do to improve your experience at BMRHC?
Your answer
If you would like to recognize a staff member who has provided you with outstanding service, please let us know by writing his/her name below:
Your answer
Additional comments:
Your answer
Thank you for completing our survey!!!!!
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