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Primary Care Connect Feedback Form
Please share your feedback about your experience. Your responses help improve care. Feedback is anonymous and safety is important.
Would you like to hear back from us?
Please provide your contact details below if you would like us to contact you about your feedback. Please note: Your contact details will only be used to respond to your feedback. You can also choose to provide feedback anonymously.
Today's date
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Month
-
Day
Year
Date
Your full name
First Name
Middle Name
Last Name
Your email address
example@example.com
Your contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any comments to make about your experience with PCC?
Getting help
Was it easy to get the help you needed from Primary Care Connect?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Did we help in your language?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Your experience
Did you feel safe?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Did you feel welcome?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Did you feel respected?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Your care
Did you have a say in your care?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Did you feel understood?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Did staff listen to you?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
Your recommendation
9) Do you know what to do next after today’s visit?
*
😀 Yes / Good
😐 A little / Okay
🙁 No / Not good
10) Would you tell a friend or family member to come to Primary Care Connect if they needed help?
*
😀 Yes / Good
🙁 No / Not good
Submit
Should be Empty: