How was your visit?

Provider's Name:
Patient First name, Last Initial:
Location:

Would you recommend this physician?

  • Highly recommended
  • Probably
  • Maybe
  • Probably not
  • Never

How would you rate this physician’ bedside manner?

  • Excellent
  • Good
  • Satisfactory
  • Unsatisfactory
  • Awful

How long was the wait time in the office before you were seen?

  • Right away
  • Less than 30 min.
  • Between 30—60 min.
  • Over 1 hour
  • Over 2 hours

How was the cleanliness of the clinic?

  • Excellent
  • Good
  • Satisfactory
  • Unsatisfactory
  • Awful

How would you rate the Medical assistant?

  • Excellent
  • Good
  • Satisfactory
  • Unsatisfactory
  • Awful

How would you rate your phone experience & ease of getting appointments?

  • Excellent
  • Good
  • Satisfactory
  • Unsatisfactory
  • Awful