- Date of visit:

Directions:

Please click on the option which best describes your experience.
(Strongly Agree, Agree, Uncertain/Unsure, Disagree, Strongly Disagree, No Opinion/Does not apply)


1. When I called to make an appointment, the call was answered promptly.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

2. I was able to make an appointment for the time and date that suited me.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

3. When I arrived for my visit, I didn't have to wait long before I was taken to the exam room.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

4. The Administrative staff (Receptionist, Check-out, Billing Staff, Manager) treated me with courtesy and respect.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

5. The Clinical staff (Nurses, Medical Assistants) treated me with courtesy and respect.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

6. My Provider treated me with courtesy and respect.*

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

7. My Provider listened carefully to me.*

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

8. I am satisfied with the way my Provider is treating my condition.*

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

9. When I call my Provider's office with questions, I am able to obtain answers in a timely manner.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

10. During my visit, my Provider used words I could understand.*

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

11. As a result of my visit to my healthcare provider, I am confident that I know how to take care of my illness(es).

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

12. Overall, I was satisfied with my experience during my visit.

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion / Does not apply

13. If you were satisfied with your visit, please comment below.

14. If you were NOT satisfied with your visit please, provide details so we can address the issue and improve.