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Patient Satisfaction Survey — Rural Health Clinic
Requested By:
John Bellamy at
Your Name:
First:
Last:
Your Phone #:
New or Existing Patient:
New
Existing
Equipment:
Model or Serial # (as applicable):
Date of Service:
(mm/dd/yyyy format)
Provider Name:
Access, Delivery and Service
Yes
No
N/A
1
I received an appointment in a timely fashion.
2
The person who answered the phone and made the appointment was courteous and helpful.
3
The wait time to be seen by a provider was timely.
4
The services I received were appropriate and addressed my needs.
5
My appointment needs were handled in a confidential and professional manner.
6
My medical questions were answered and addressed in a way that I understood.
7
I have been informed and understand my diagnosis.
8
I have been informed of and understand the treatment plan.
9
All of the staff that I interacted with treated me respectfully and professionally.
10
I was 100% satisfied with my overall experience and the health services provided.
Comments
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