Patient Survey

We'd love to hear your thoughts about our clinic and how we can help better serve you. Please fill out the survey form below...thank you!

Please provide your contact info:

First Name: (required)

Last Name: (required)

Phone Number:

Please tell us how you found out about Premier Urgent Care :

Do you have a regular family doctor?

 Yes No

If Premier Urgent Care was not here, where would you have gone for treatment? :

 Emergency Room Family Doctor Would have had no treatment Other

Which location did you visit today?

 Alexandria Pineville

Have you previously visited this location of Premier Urgent care?

 Yes No

How would you rate:

Overall quality of medical care?

 Excellent Good Fair Poor

Courtesy and helpfulness of front desk staff?

 Excellent Good Fair Poor

Courtesy and professionalism of Nursing staff?

 Excellent Good Fair Poor

During your visit were you periodically informed of the status of your treatment and offered water or other conveniences?

 Yes No

Based on your recent appointment, how would you rate your PROVIDER
-Listens to you

 Excellent Good Fair Poor

-Takes Enough Time with you

 Excellent Good Fair Poor

-Explains your Plan of Care

 Excellent Good Fair Poor

-Satisfaction with your Plan of Care.

 Excellent Good Fair Poor

Cleanliness and neatness at Premier Urgent Care?

 Excellent Good Fair Poor

Clear communication and instructions during visit?

 Excellent Good Fair Poor

How would you rate your WAIT TIME IN
-Waiting Room

 Excellent Good Fair Poor

-Exam Room

 Excellent Good Fair Poor

Was the cost of your visit reasonable?

 Yes No

How likely would you be to refer to friends & relatives?

 Very Likely Somewhat Likely Somewhat Unlikely Not at all Likely

Overall, how would you rate your Experience?

 Excellent Good Fair Poor

Overall, were you satisfied enough to return to our center for medical care in the future?

 Yes No

Would you be willing to share your experience in Premier Urgent Care marketing initiatives?

 Yes No

What was the date of your visit?
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We’d like to hear any comments you might have about your visit to our clinic.

To improve our services and better serve our clients, we may wish to contact you regarding your feedback. What is your e-mail address? (Note that your e-mail address will only be used to contact you if appropriate and will not be used for any other purpose.) :

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