Survey

Patient Satisfaction Survey

Completion of this survey is voluntary and all responses are kept confidential.
However, if a name is provided we will contact you with feedback.

How would you rate your satisfaction with the length of time you waited to get your appointment? Excellent Very Good Good Fair Poor

Was it a booked appointment or were you seen in Urgent Care?

Booked Appointment
Urgent Care

How would you rate your satisfaction with your wait time once you were checked in? Excellent Very Good Good Fair Poor

How would you rate the helpfulness of our staff? Excellent Very Good Good Fair Poor

How would you rate your satisfaction of the care you received with your health care provider? Excellent Very Good Good Fair Poor

How would you rate your satisfaction with getting through to the office phone? Excellent Very Good Good Fair Poor

Any Additional Comments

Name

Telephone (Daytime)

Age

Town

Which care provider did you see?

	Healthy Eating Education
	Parent Support Group - Youth & Addication
	Stress Reducation Education
	Smoking Cessation Education
	Pain Management Education
	Osteoporosis Education
	Healthy Eating for Cholesterol
	Emotional Eating Education
	Diabetes Education
	COPD Education
	Asthma Education