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Care Improvement Questionnaire
We would like to know how you feel about the services we provide so that we can improve on those services and make sure we are meeting your needs. Your responses are directly responsible for improving these services.
All responses are kept confidential and anonymous.
Thank you for your time.
Please select how well you think we are doing in the following areas:
Excellent
/
Good
/
Ok
/
Fair
/
Poor
1. Ease of getting care
*
Indicates required field
Ability to be seen
*
Excellent
Good
Ok
Fair
Poor
Prompt return of calls
*
Excellent
Good
Ok
Fair
Poor
2. Waiting
Time in waiting room
*
Excellent
Good
Ok
Fair
Poor
Time in exam room
*
Excellent
Good
Ok
Fair
Poor
Waiting for test results
*
Excellent
Good
Ok
Fair
Poor
3. Staff
Listens to you
*
Excellent
Good
Ok
Fair
Poor
Takes enough time with you
*
Excellent
Good
Ok
Fair
Poor
Explains what you want to know
*
Excellent
Good
Ok
Fair
Poor
Friendly and helpful to you
*
Excellent
Good
Ok
Fair
Poor
Answers your questions
*
Excellent
Good
Ok
Fair
Poor
4. Facility
Neat and clean rooms
*
Excellent
Good
Ok
Fair
Poor
Ease of finding where to go
*
Excellent
Good
Ok
Fair
Poor
Comfort while waiting
*
Excellent
Good
Ok
Fair
Poor
Keeping personal information private
*
Excellent
Good
Ok
Fair
Poor
5. Any suggestions for improvement ?
Comment
*
Thank you for taking the time to complete our survey!
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