Clinic Pilot Project

Thank you for taking the time to complete this survey. Please answer the following questions to the best of your ability.

Gracias por tomar el tiempo para responder a esta encuesta. Por favor conteste las siguientes preguntas lo mejor que pueda.

Date you Received Care
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

Please enter your responses below:

Por favor marque sus respuestas en las siguientes preguntas:

1. I was able to receive my appointment when I needed it I was able to receive my appointment when I needed it

   Strongly Agree

   Agree

   Disagree

   Strongly Disagree

2. This provider/staff listened and showed respect for my concerns This provider/staff listened and showed respect for my concerns

   Strongly Agree

   Agree

   Disagree

   Strongly Disagree

3. Would you recommend this provider to your friends and family? Would you recommend this provider to your friends and family?

   Definitely Yes

   Probably No

   Probably Yes

   Definitely No

4. Please tell us one thing we could have done better and add any additional comments you may have about your visit today. Please tell us one thing we could have done better and add any additional comments you may have about your visit today.