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1.Which clinic did you visit last?

2.Which provider did you see during that visit?

Ease of Getting Care

3.How easy was it to get through by phone?

4.Do our hours of operation meet your needs?

5.If you left a message with us, was your call returned within 3 days?

6.At what times do you want to be able to see your Care Team/Provider?


7.Was the waiting room time reasonable?

8.Was the time in the exam room reasonable?

Staff Courtesy (Doctor/Dentist/Counselor)

9.How well did your provider listen to you and answer your questions?

10.Did your provider talk to you about specific goals for your health?

11.Have we helped you find other services you need that we don't offer?

12.Do you feel we helped you make healthy lifestyle choices?

Staff Courtesy (Nurse/Medical Assistant/Dental Assistant)

13.Was your Nurse/Medical Assistant/Dental Assistant friendly and courteous?

14.Did s/he respect your privacy?

15.Do you feel s/he listened to you and answered your questions?

Staff Courtesy (Front Office/Registration Staff)

16.Were the Front Office/Registration Staff friendly and courteous?

17.Did s/he respect your privacy?

18.Do you feel s/he listened to you and answered your questions?


19.How clean was the facility?


20.How did you get to the clinic today?

21.Your Race:

22.Your Ethnicity:

23.Your Age Range:

24.Would you recommend the clinic to a family member or friend?

25.If you answered Maybe, No or Don't Know, please explain below

26.Additional Comments

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