Falls Church Healthcare Center - Appointment Survey

1
Overall, please tell us how you would rate your most recent experience with Falls Church Healthcare Center.
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Very poor
Excelllent
2
It was easy for me to locate Falls Church Healthcare Center.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
3
I felt safe entering Falls Church Healthcare Center for my appointment.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
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I was able to check in for my appointment quickly and easily.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
5
A staff member began my services soon after I arrived.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
6
The staff at FCHC reviewed the steps of my appointment thoroughly.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
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The staff at FCHC answered the questions I asked to my satisfaction.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
8
The staff at FCHC treated me respectfully.Please indicate how strongly you agree or disagree with this statement.
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Strongly Disagree
Strongly Agree
9
Was there a staff member or an experience which you found outstanding at your in-person appointment?
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Ok
Ok
10
What brought you to Falls Church Healthcare Center for your appointment?
Abortion Care
Gynecology Appointment
Other
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How did you request your appointment?
Online through our website
By telephone
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How easy was it to make an appointment with us?
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Very difficult
Very Easy
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Do you have any additional comments about making your appointment with us over the phone?
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Ok
Ok
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Do you have any additional comments about making your appointment with us online?
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Ok
Ok
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Did you receive a text message to confirm your appointment and a text message to remind you about your appointment?
YESNO
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Did you complete your Patient Forms online through our website?
YESNO
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If you did NOT complete your forms online, what was the reason?
I did not know this was an option
The process was too difficult
I prefer to complete the forms in a language other than English
I did not have access to a device to complete the forms online
Other
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If you completed your forms online, how easy was it to do so?
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Very Difficult
Very Easy
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Do you have any additional comments about completing your forms online?
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Ok
Ok
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Did you participate in our Telehealth Patient Education Experience?
YESNO
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Why did you decide NOT to have your patient education experience through Telehealth?
I did not know this was an option
The times available were not convenient
I did not have access to equipment to do so
I felt more comfortable talking to a staff member in person
Other
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How easy was it for you to participate in your Telehealth session?
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Very Difficult
Very Easy
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How satisfied were you with your Telehealth appointment?
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Not at all satisfied
Very satisfied
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Was there a staff member or an experience which you found outstanding at your Telehealth appointment?
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Ok
Ok
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How likely are you to recommend Falls Church Healthcare Center?
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Not at all likely
Very likely
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What suggestions do you have to improve the patient experience at FCHC?
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Ok
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Falls Church Healthcare Center is holding a monthly drawing for a gift card for patients who have completed this survey! Would you like to participate in the drawing? We will request your name, email address and street address below. Your personal information will not be linked with the answers you provided above.
YESNO
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Name
First Name
Last Name
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Email
example@example.com
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Address
Street Address
Street Address Line 2
City
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Postal / Zip Code
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