Backround Information
Gender
Male
Female
Rather Not Say
Age
Less than 18
18-34
35-54
55-64
65 or Older
Date of Visit:
Name of Provider:
Please check the box that best describes your experience
Access To Care
1. Time required to to schedule an appointment with your doctor
Highly Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Highly Satisfied
2. Overall helpfulness of staff
Highly Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Highly Satisfied
Your Office Experience
1. Amount of time spent in waiting room before taken to exam room
Highly Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Highly Satisfied
2. Thoroughness of doctor's exam
Highly Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Highly Satisfied
3. Overall satisfaction with my visit
Highly Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Highly Satisfied
Please feel free to add any additional comments
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