School-Based Health Clinic Survey
Name
*
First Name
Last Name
Email
*
example@example.com
Which school or schools do your children attend?
*
How satisfied are you with the experience you and your child(ren) had with QUICKmed?
*
Very satisfied
Satisfied
Not satisfied
Very unsatisfied
Do you have any concerns or questions about the services that QUICKmed provides?
*
Have you utilized the following services for your child or children? Check all that apply.
School clinic for sick visit
School clinic for well visit
Other QUICKmed Urgent Care location
None of the above
Do you currently have a primary care provider?
Yes
No
Are you aware that the school provides primary care services such as well visits and treatments for other health services?
Yes
No
Did you know that you can use a school-based health center and your primary care physician for the same services?
Yes
No
What would prevent you from using medical services offered at the school's location? Check all that apply.
Transportation
Job
Hours of operation
Other
If you selected "Other" for the previous question, please explain.
Are you interested in any of the other services that QUICKmed offers? Check all that apply.
Primary Care
Allergy Testing
Mental/Behavioral Health
Submit
Should be Empty: