Your Race/Ethnicity:
Please check all that apply: *
Medical Conditions:
Please mark how well you think we are doing in the following
 
YOUR APPOINTMENT
1 Ease of making your appointment:
2 Appointment available within a reasonable amount of time:
3 The efficiency of the check-in process:
4 Waiting time in the waiting room:
5 Waiting time in the exam room:
6 Keeping you informed if your appointment time was delayed:
OUR STAFF
1 The courtesy of the person who took your call:
2 The friendliness and courtesy of the front desk staff:
3 The caring/concern of our nurses/medical assistants:
4 Did your nurse or medical assistant use the hand sanitizer prior to and after seeing you?
5 The friendliness and courtesy of the EAFHC Pharmacy/Pharmacy tech:
OUR COMMUNICATION WITH YOU
1 Your test results reported in a reasonable amount of time:
2 The nurses ability to return your calls in a timely manner:
3 The providers ability to return your calls in a timely manner:
4 Did you know that you can contact us after hours?
5 Are you able to obtain prescription refills when requested?
YOUR VISIT WITH THE PROVIDER
1. Willingness to listen carefully to you:
2 Taking time to answer your questions:
3 Explaining things in a way you could understand:
4 The thoroughness of the examination?
5 Support and assist you with setting goals to change your health habits and health care decisions:
6 Makes arrangements for your care to the proper specialist and/or resources needed?
7 Did your provider use the hand sanitizer prior to and after seeing you?
OUR FACILITY
1 Convenient hours of operation:
2 Convenient hours of EAFHC Pharmacy operation:
3 Cleanliness and general appearance of the center:
4 Do you consider this center your regular source of care?
5 Do you feel the nominal fee of $20 is reasonable?
YOUR OVERALL SATISFACTION WITH
1 Our center:
2 The quality of your medical care:
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