Patient Survey - Urgent Care

Patient Satisfaction

We want you to be satisfied with the service and care you receive from our staff and physicians as well as from those to whom we may refer you. If you have any questions or concerns about the care you receive, please contact us as soon as possible. It is especially important that you do this immediately if you believe your health may be affected. You may wish to complete the on-line patient satisfaction survey to provide us with feedback on the services we provided you.

How would you rate:

Poor

Fair

Good

Excellent

1.	Overall quality of medical care?

2.	Courtesy and helpfulness of front desk staff?

3.	Courtesy and professionalism of medical staff?

4.	Cleanliness and neatness of Urgent Care Center?

5. Overall visit time?

6.	Clear communication and instructions during visit?

7.	Was your waiting time before being seen by a physician acceptable? YES NO

8.	Have you been to a Sisters of Mercy Urgent Care Center before? YES NO

9.	If this is your first visit, please tell us how you found out about the Urgent Care Center.

Family / friend	Workplace	Doctor referral	Internet search
Newspaper	Billboard	Television	E-mail
Direct mail	Radio	Web site	Other:

10. Do you have a regular family doctor? YES NO

11.	If the Urgent Care Center were not here, where would you have gone for treatment?

Emergency room

Family doctor

Wouldn't have
sought treatment

Other:

12. Was the cost of your visit reasonable? YES NO

13.	Overall, were you satisfied enough to return to our center for medical care in the future? YES NO

14.	We’d like to hear any comments you might have about your visit to our center.

15.	To improve our services and better serve our clients, we may wish to contact you regarding your feedback. What is your e-mail address? (Note that your e-mail address will only be used to contact you if appropriate and will not be used for any other purpose.)

16.	To further investigate your feedback, what is your Patient Account #? (This is located in the upper left hand corner of your discharge form.)

17.	Date of service:

18.	Center visited:

The security and confidentiality of your personal health information are important to us. Our e-mail is not encrypted and, thus, could be viewed by other parties during transmission. Therefore, we ask that you do not send personally identifiable health information to us via e-mail.

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