Patient Satisfaction Survey

Instructions: Please complete the following survey. Your responses will be used to improve our services. All responses are anonymous, unless you choose otherwise. Thank you for your time.

Which clinic did you attend?

Family Planning

Immunizations

Please select the response that best matches how you feel.

Questions	Poor	Fair	OK	Good	Great
Convenience of the clinic location (Consider travel time, access by public transportation, and parking)	Poor	Fair	OK	Good	Great
Accessibility of the office (Is the office easy to find, are stairs or elevators readily available, is handicapped entrance adequate)	Poor	Fair	OK	Good	Great
Hours clinic is open	Poor	Fair	OK	Good	Great
Time spent waiting to see a provider (Physician, Physician Assistant, Nurse Practitioner, Nurse)	Poor	Fair	OK	Good	Great
Time spent with the provider (Physician, Physician Assistant, Nurse Practitioner, Nurse)	Poor	Fair	OK	Good	Great
Cleanliness of the office, including the reception area and examination rooms	Poor	Fair	OK	Good	Great
Courtesy of the staff	Poor	Fair	OK	Good	Great
Cost & how payment is collected	Poor	Fair	OK	Good	Great
Quality of the care you received	Poor	Fair	OK	Good	Great
Keeping my personal information private	Poor	Fair	OK	Good	Great

Do you consider this clinic your regular source of care?

Yes

Will you refer your friends and relatives to this clinic?

Yes

What do you like best about our clinic?

What do you like least about our clinic?