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We would like to know how you feel about the services we provide so we can make sure we are meeting your needs.
Your responses are directly responsible for improving these services.
All responses will be kept confidential and anonymous.
Thank you for your time.

Fields marked (*) are compulsory

Your Age: *   Your Sex: *   Male Female
 
Ease of Getting Care:

Poor = 1 | Great = 5

Ability to get in to be seen: *   1 2 3 4 5
Hours Center is open: *   1 2 3 4 5
Convenience of Center's location: *   1 2 3 4 5
 
Waiting:

Poor = 1 | Great = 5

Time in waiting room: *   1 2 3 4 5
Time in exam room: *   1 2 3 4 5
 
Staff:

Provider: (Physician, Physician Assistant, Nurse Practitioner)

Poor = 1 | Great = 5

Listens to you: *   1 2 3 4 5
Takes enough time with you: *   1 2 3 4 5
Explains what you want to know: *   1 2 3 4 5
Gives you good advice & treatment: *   1 2 3 4 5
 

Nurses and Medical Assistants:

Poor = 1 | Great = 5

Friendly and helpful to you: *   1 2 3 4 5
Answers your questions: *   1 2 3 4 5
 

Facility:

Poor = 1 | Great = 5

Neat and Clean building: *   1 2 3 4 5
Ease of finding where to go: *   1 2 3 4 5
Privacy: *   1 2 3 4 5
 

Confidentiality:

Poor = 1 | Great = 5

Keeping my personal information private: *   1 2 3 4 5
The likelihood of referring your
friends & relatives to us: *		   1 2 3 4 5
What do you like best about our Center?  
What do you like least about our Center?  
Suggestion for improvement?  
Thank You for completing our Survey
Would you like someone to Contact you
in regard to yoru visit?*		   Yes No
If you selected Yes please fill out the following information below:
Name     
Phone     
E-Mail Address *  
What is Your Age? *  
Enter the code as it is shown: *  
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