Satisfaction Survey

As your local healthcare provider we continually look for ways to offer the best patient care and service. If you have used our facilities we would appreciate hearing how we did. All information you provide is strictly confidential. Thank you for your participation.

Rating Scale:
1 = Very Unsatisfied
2 = Unsatisfied
3 = Neither Satisfied nor Unsatisfied
4 = Satisfied
5 = Very Satisfied
N/A = Not Applicable

Quality of Care Received

                       
Please answer this question.
Overall Responsiveness of Staff

                       
Please answer this question.
Cleanliness of Hospital/Clinics

                       
Please answer this question.
Overall Rating of Facilities
                       
Please answer this question.

Additional Information

Physician that you saw:
Comments:

Your Information

If you'd like us to contact you about this survey, please include your information below.

First Name:
Last Name:
Email Address: