Patient Visit Survey
We would like to know how we can improve our service to you. Please take a few minutes to answer the following. We value your opinion and want to thank you for taking the time to help us serve you better. Thank you!
Sign in to Google to save your progress. Learn more
Who is taking this survey?
Clear selection
Which provider did you see at Mill Creek Family Practice?
Clear selection
Is this the provider you usually see for appointments, health advice, or if you are sick?
Clear selection
In the past year when you have called Mill Creek Family Practice to get an appointment, were you able to get an appointment as soon as you needed?
Clear selection
In the past year when you have called Mill Creek Family Practice during regular office hours, how often did you get an answer to your medical questions that same day?
Clear selection
In the past year when you called Mill Creek Family Practice after regular office hours, how often did you get an answer to your medical question as soon as you needed?
Clear selection
In the past year how often did you see your healthcare provider within 15 minutes of your appointment time?
Clear selection
During your most recent visit, did your healthcare provider give you easy to understand information about your health questions or concerns?
Clear selection
During your most recent visit, were staff at Mill Creek Family Practice as helpful as you thought they should be?
Clear selection
On a scale of 1-5 with 5 being the highest, how would you rate your overall satisfaction with Mill Creek Family Practice?
Very Low
Very High
Clear selection
How long has the patient been seen by this practice?
Clear selection
Please select the patient's gender
Please select patient's age
Please feel free to share thoughts about your recent visit below
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms