Name
Your Email
Health History
What was the date of your most recent appointment?
How did you find out about us?
What location did you go?
Ease of making appointments by phone
Appointment available within a reasonable amount of time
Getting care for illness/injury as soon as you wanted it
Getting after-hours care when you needed it
The efficiency of the check-in process
Waiting time in the reception area
Waiting time in the exam room
Keeping you informed if your appointment time was delayed
Ease of getting a referral when you needed one
The courtesy of the person who took your call
The friendliness and courtesy of the receptionist
The caring concern of our nurses/medical assistants
The helpfulness of the people who assisted you with
The professionalism of our lab or x-ray staff
Your phone calls answered promptly
Getting advice or help when needed during office hours
Explanation of your procedure (if applicable)
Your test results reported in a reasonable amount of time
Effectiveness of our health information materials
Our ability to return your calls in a timely manner
Your ability to contact us after hours
Your ability to obtain prescription refills by phone
Willingness to listen carefully to you
Taking time to answer your questions
Amount of time spent with you
Explaining the skin, hair or nail conditions in a way you could understand
Instructions regarding medication/follow-up care
The thoroughness of the examination
Advice given to you on ways to stay healthy
Hours of operation convenient for you
Our practice
The quality of your medical care
Your provider
The staff nurse
WOULD YOU RECOMMEND US TO OTHERS? PLEASE TELL US WHY:
THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT
Would you like to receive a call from us regarding your visit?
GENDER
YOUR AGE
REASON FOR VISIT
ONLINE OR IN-PERSON
Time's up
