Patient Feedback
Please submit feedback regarding the recent visit you have just completed, including feedback on your provider interaction, clinic appearance and the team. THANK YOU!
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Which location did you visit?  *
Rate the interaction with your provider on a scale of 1-5, 5 being very good and 1 being very poor.  *
Let us know what made your experience a 3 or lower with your provider.
Clinic Appearance *
Poor
Fair
Satisfactory
Very good
Excellent
The clinic was clean, organized, and free of clutter?
The provider room your visit took place in was clean, organized, and free of clutter?
How would you rate the overall cleanliness of Central Outreach Wellness Center?
Ease of Scheduling *
Yes
No
Not Applicable to my visit
Was it easy to book an appointment with our team?
Did you get an appointment date closest to when you were needing to see your provider?
Were you provided a scheduled follow-up appointment?
The Team *
Yes
No
I do not have insurance.
Was the team friendly, welcoming, and organized?
Were you asked for your ID and Insurance card?
Did you find it easy to work with the front desk and check-out desk team member(s)?
Did the team sign you up for Case Management if you reported not having insurance?
Was your information reviewed with you for accuracy?
How would you improve your overall experience?
How did you hear about and choose Central Outreach Wellness Center for your care? *
Please provide your name and phone number and date of visit. 
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