You are on page 1of 2

Sosd

Faxnily ffractice "Good Life, F{ealrh e Wellness."
fr,f,f;c
Survey
can
'i t

Patient Satisfaction

We would like to know how you feel about the services we provide so we [" make maKe sure we are meeting your needs. Your responses are qlrefily responsible forlii We meellng neeos. directly responslole TOrf ii improving these services. All responses will be kept confidential and anonymous. ['': Thank you for your

time.

I

Ymur &gm:

Ycur Sex:

Male

Female

Yrur ftace/fthnirity:
Asian Facific lslander

ffi

SIark/Afrif,#n Arn*rfran
Unknmwn

@

American lndian/Alaska Nativ* kVhits {Not Hispanic *r Latin#} I"{ispanic ar Latino {AIl Races}

Please circle how well you think we are doing in the following areas: FAIRPOOR. 1 GREATOK.

5

GOOD.4

3

2

Ease of getting t&rex

5
T1 {t
tt tt al
ft lt

4
at I' ta

-{
*r,, tl tt !r tt

2
tt tt

3"
!t

Ability tn get in tm he s#en: Hours Center is #p*n: Csnvenience af C*nterns l*catirn: Frarnpt return 0n calls: Waiting: Tlrrre [n w*ltlng room: Timm [n exfrrrt rocm: \rVnitlng fmr tests ts be perfmrrffied:
Walt$ng

a1

tt

; {}
tl
EI

tr"
tt IN TI

,t TT

TI \I

TT
II II

!t

f'r T'
gt It tt

:

II tt

lt ll

fi
tt

tl II II

t! II
tt ET

il

t3
tt II I'

TI
L}
II
lt

TI

TT
at II

tJ
tt

tt II

+"J

ftr

tt tt ft

EI II II

f*r t*st r#sults;
{Turn over

t1

I} t,

tl IT

LJ

ft

tr TT at

t* c*!nplet*}

SCI*d [if;e Sarmily Practfic*
ffiffiB$"#ruEn aHffi Seea"%rffiy
Staff;
Frmvider: Listens tr ysLJ: Takes en*ugh time rruith yffr.t: fixplains what y#u want t* know: ffilv*s y*u gc*d advice and treatrnents: [\lurses and Medical AssistantE:
tt tt l, F *"8

4
tt ll

3
,I !t II It tt {l

?.

3"
tl II II

f1
fl
ta'

f1 TI
TI ,t

II
ll tt t{

II

al I"J

tt II t!

17
II II

{1 tt
II tt lt II

TJ
,l

t,

!l II II

"J
.T tt tt
ti TI

II

+T

tl !i

t\
tr

LI
tt l, It

tl

f1
It

tt

Friendly and helpful tm ynu: Ansu/ers your questipns:
AII ffther$: Fr[mndty and helpful t* ystr: Answers ysur questlons:

ft
!T

ft
II

r\
t{ It {l !l

ft
l!

IT

lt

tt

IJ

fI

TT
at

tt lt

II

tt
II

r\
a-J

tl

tt ll

r./
fl

ft II tt

at
TI

tt
I'

ll

Payment l What you pny: Hxplanatinn mf charges: Csllectls n of payrnent/rnsney:
Faeility: Neat and clean huilding:
Hase

tt
la

tt

tt
tI

/*t
AJ

tl Ii at

tl
tt

tt t, TI
at

la

f1
TI

IT
t1

tl

lt

It

!I t,

(.J

TI IT

fl

IT
II

El

tl fI !t

TJ
tt

r.J
tl

tt
It

II

ft
tt It l.l

rf findins wh*r* tn g*:

tt

It

rI tt .T

tt II

tcmfmrt and Safety kvhile wfriting:

L}

fl
I'

ra II II

t! r"J

fi

Wuuld you r*fer your friends and relfitives tu us? kVhat dc y#Lr like hest abcut our f,*nter?

y8s

ffis

What do you like least about our Center?
Suggestions for i mproveme nt?
Thank you for completing our Survey!