Clinic evaluation survey

Facility   Poor Good Excellent Please comment your choice Convenience of operation hours Comfort of the office Appearance of the office Waiting room quality Overall comfort Parking Signage and directions Security level The office is: Very easy to find Somewhat easy to find Difficult to find It is almost impossible to find the office without a guide Please indicate the areas in which this office can improve   Areas to Improve Comments Better magazines in the reception area Friendlier staff More information on my condition Less waiting time More concern from the doctor Better parking More time with the doctor Other: Time   Too short Short Just right Long Too long The amount of waiting time in the reception area is The amount of waiting time in the exam room is The amount of time the staff spent with you is The amount of time the physician spent with you is How long did you wait from time of check in until you saw the doctor? Please select one ... less than 15 min 15-30 min 30 min-1 hr 1-2 hr 2-3 hr 3-4 hr 4-5 hr 5-6 hr 6-7 hr 7-8 hr more than 8 hr Method of Payment Please select one ... Self Pay Cash Insurance-Other Insurance-HMO Medicare Medicaid Medi-Cal Contact information Name   Organization   Address   City and state   ZIP code   E-mail   Phone   How likely are you to refer your friends and neighbors to this clinic? Highly likely Likely Neutral Unlikely Highly unlikely Please describe your recent visit to our clinic. It was your first visit It was your 2'nd - 4'th visit It was your 5'th or more visit

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