Thank you for taking the time to provide feedback. Your responses are completely confidential and will be used only to improve the quality of care and services we provide. This survey should take only a few minutes to complete.

For the following questions, please rate your experience on a scale of 1 to 10, where:
1 = Not at all satisfied / Poor
10 = Extremely satisfied / Excellent

1. How satisfied are you with the ease of scheduling appointments?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 2. How would you rate the professionalism and courtesy of the administrative staff?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 3. How comfortable do you feel in the clinic’s physical environment (waiting room, cleanliness, privacy)?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 4. How well does your provider listen to your concerns?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 5. How respected and understood do you feel by your provider?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 6. How clearly are treatment goals and plans communicated to you?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] * 7. How would you rate the overall quality of care you receive at this clinic?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 8. How likely are you to recommend this clinic to others?
[ 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 ] 9. What can we do better to improve your experience with our clinic?
Please write your response below: