Background Information
Facility
Survey Entry Month
Date Of Your Visit
Name of your Physician
Time Arrived
Time Left
Arrival
Facility Appearance
Were you greeted right away
Comfort of the Patient Lounge
Degree to which you felt welcome
Explanation of billing
Your wait time in Patient Lounge
Level of Professionalism shown by the Patient Relations Specialist
Medical Assistant
Courtesy of the Medical Assistant
Medical Assistant Helpfulness
Level of Professionalism shown by the Medical Assistant
Comfort Of Exam Room
Physician
Courtesy of the Physician
Physician Helpfulness
Level of professionalism shown by the Physician
Wait time in the exam room
Radiology Technician
Wait time for x-rays
Courtesy shown by Radiologist staff
Level of professionalism shown by Radiology staff
Overall Impressions
Were you informed of any delays?
If needed again would you use us again?
Would you recommend Americas Urgent Care?
Are you familiar with our other location?
Positive aspects or outstanding staff?
Opportunities for improvement
How did you hear about America's Urgent Care?
Other Referral Source
About You
Name
Address
May We contact you about your visit?
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