Patient Satisfaction Survey

Please Tell Us How We Are Doing on Your Last Visit or Today's Visit

We want to know how you feel about the care you get at our health center. Please take a few minutes to complete this survey and then return it to us. Your answers are important to us.

About Patient

Yes No    
Yes No    

Ease of Getting Care

Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor

Facility

Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor

Front Desk

Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor

Provider (the person who took care of you)

Very Good Good Fair Poor
Very Good Good Fair Poor
Very Good Good Fair Poor

General

Yes No No Opinion  
Yes No No Opinion