Clinic Visit Survey
1. Which of our three clinics have you recently visited?
Julesburg, CO
Big Springs, NE
Chappell, NE
2. What day was your appointment?
Monday
Tuesday
Wednesday
Thursday
Friday
3. Was it easy to schedule and check in/out?
Yes
No
If you experienced problems, please share what occurred:
4. Please share your experience with the clinic nurse/MA who assisted you.
Excellent - no complaints!
Very good - She was friendly and knowledgeable
Needs improvement - Please enter your suggestion in the text box below
Poor - Please enter your experience and suggestions in the text box below
If you were not happy with your interaction with the clinic nurse/MA, please share your comments with us.
5. Did your provider address your concerns?
Yes
No
If you answered No, please share your experience in the comment box.
6. Did you understand your diagnosis and treatment plan?
Yes
No
7. Overall satisfaction with your visit:
Satisfied
Dissatisfied
If you were dissatisfied with your visit, please share your comments below.
Additional comments or suggestions:
Thank you for taking our survey! We appreciate your feedback!
Submit
Should be Empty: