We Care About Your Opinion

WHICH CLINIC LOCATION DID YOU VISIT?
HOW DID YOU FIRST MAKE CONTACT WITH OUR STAFF?
HOW WELL WAS THE PROGRAM EXPLAINED TO YOU ON THE FIRST CONTACT?

Very Well
Somewhat
Minimally
Not At All

(Please rate 1-5, with 1 being poor and 5 being Excellent)
HOW WAS YOUR OVERALL CLINIC EXPERIENCE?
1
2
3
4
5
HOW WAS YOUR EXPERIENCE WITH THE TRIAGE NURSE?
1
2
3
4
5
HOW WAS YOUR EXPERIENCE WITH THE NURSE PRACTITIONER/DR ?
1
2
3
4
5
HOW WAS YOUR EXPERIENCE WITH THE NUTRITION COUNSELOR?
1
2
3
4
5
HOW WAS YOUR EXPERIENCE WITH THE FRONT DESK STAFF?
1
2
3
4
5
WHAT DID YOU LIKE MOST ABOUT YOUR VISIT?
IS THERE ANYTHING WE COULD DO TO IMPROVE YOUR VISIT?
WILL YOU RETURN TO OUR CLINIC?
Yes
No
WOULD YOU LIKE US CONTACT YOU REGARDING THIS SURVEY?
Yes
No
IF YES, WHAT IS YOUR EMAIL ADDRESS?