General Information |
Patient Name |
|
Patient E-mail Address |
|
Patient Gender |
|
|
|
|
Male
Female
|
| |
Patient Date of Birth |
|
Patient Date of Visit |
|
Location of Visit |
|
|
|
|
|
| |
Was this your first visit to MedHelp Clinics? |
|
Provider Name |
|
Yes
No
|
|
|
| |
Staff Courtesy and Professionalism |
Clerical/Front Office Staff |
|
Nurses, Lab Techs, and X-Ray Techs |
|
Care Provider |
|
4
3
2
1
N/A
|
|
4
3
2
1
N/A
|
|
4
3
2
1
N/A
|
| |
Attention given to your healthcare needs by your Care Provider (Physician or Nurse Practicioner) |
|
How long was your office visit today? |
|
What will be your overall assessment of today's visit? |
|
4
3
2
1
N/A
|
|
Less than an hour
1 - 2 hours
2 - 3 hours
Greater than 3 hours
|
|
4
3
2
1
N/A
|
| |
Cleanliness and appearance of the facility |
|
Would you recommend our clinic to others? |
|
How did you hear about MedHelp Clinics? |
|
4
3
2
1
N/A
|
|
Yes
No
|
|
TV
Internet
Word of Mouth
Yellow Pages
Location
Other
|
| |
Please feel free to write any additional comments that you feel might help us to improve our service. |
|
|
|
