Patient Survey

1

Who is your physician?

David Harrover

David Hogue

Frederick Merrill

Kelley Mondi

Stephen Schmidt

Hailie Volpitto

2

Easy to schedule appointmentsPlease rate your experience.

1
2
3
4
5

Worst

Best

12

If you have seen an employee giving exceptional care, please provide a name and details below as we would like to recognize staff members who do a great job.

13

What do you like most about FPE?

14

What do you like least about FPE? What are your suggestions on how we can improve?

15

Would you refer a friend to Family Physicians of Evans

Yes

No

16

Would you like a follow up call or email from FPE about your experience?

Yes (please provide contact info on the next slides)

No

17

Name

18

Phone Number

Area Code

Phone Number

19

Email

example@example.com