Patient Survey 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 *Last NamePhone Number *Which location did you visit? *AlexandriaPinevilleJenaWhat was the date of your visit? *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925How would you rate :Overall quality of medical care? *ExcellentGoodFairPoorCourtesy and helpfulness of front desk staff? *ExcellentGoodFairPoorCourtesy and professionalism of nursing staff? *ExcellentGoodFairPoorDuring your visit, were you periodically informed of the status of your treatment and offered water or other conveniences? *YesNoBased on your recent appointment, how would you rate your PROVIDER?Listens to you *ExcellentGoodFairPoorTakes enough time with you *ExcellentGoodFairPoorExplains your plan of care *ExcellentGoodFairPoorSatisfaction with your plan of care *ExcellentGoodFairPoorCleanliness and neatness of Premier Urgent Care? *ExcellentGoodFairPoorClear communication and instructions during visit? *ExcellentGoodFairPoorWait time in - WAITING ROOM *ExcellentGoodFairPoorWait time in - EXAM ROOM *ExcellentGoodFairPoorWas the cost of your visit reasonable? *YesNoOverall, how would you rate your experience? *ExcellentGoodFairPoorHow likely would you be to refer to friends & relatives? *Very likelySomewhat likelySomewhat unlikelyNot at all likelyOverall, were you satisfied enough to return to our center for medical care in the future? *YesNoWould you be willing to share your experience in Premier Urgent Care marketing intiatives? *YesNoWhat was the date of your visit? *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925We'd like to hear any comments you might have about your visit to our clinic. *To improve our services and better service our clients, we may wish to contact you regarding your feedback. What is your email address?(Note that your email address will only be used to contact you if appropriate and will not be used for any other purpose.)Send Message
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