How Was Your Visit?

We would like your opinion about the services you received. Your feedback will help us know where we are successful in meeting your needs and where we may need to improve. Thank you for your time!

Visit Date (mm/dd/yyyy)
Provider

Please rate the services you recieved

Ease of Getting Care
Telephone is answered promptly when you call
Ability to get in to be seen
Waiting
Time in waiting room
Time in exam room
Office Staff, Medical Assistant, and/or Nurse
Friendly and courteous to you
Helpful
Provider (Physician, Nurse Practioner, or Physician Assistant)
Listens to you
Has necessary medical information about you
Discusss your medications with you
Aware of care you receive from other providers
 
Name
Contact Information (Email or Phone #)
Would you like to us to contact you?
Is there anything else you want us to know or would like to share with us?
(Your responses are anonymous unless you mention your name)
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