Francis Holistic Medical Center Feedback
How are we doing?
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Your Name:
Patient Name (if different):
Mailing Address:
City:
State:
Zip Code:
Home Phone:
Email Address:
Patient Gender:
Patient Age:
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What service did you come in for with this visit?:
Allergy Testing
Allergy Shot or Other Injection
IV Therapy
Appointment with Dr. LaCava
Appointment with Dr. Lerner
Appointment with Dr. Morrissey
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What time of day did you come in?:
8:00 am - 10:00 am
10:01 am - 12:00 pm
12:01 pm - 2:00 pm
2:01 pm - 4:00 pm
After 4:00 pm
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How many times have you visited our center?:
First Visit
2 - 5 Visits
More than 6 Visits
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Please rate the courtesy of our receptionist.:
Very Courteous
Somewhat Courteous
Neutral
Somewhat Discourteous
Rude
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How long was your wait for your appointment?:
0 - 5 minutes
5 - 20 minutes
20 - 40 minutes
Over 40 minutes
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Please rate the proficiency of the Nursing Staff.:
Outstanding!
Good
Adequate
Needs Improvement
Poor
N/A
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Would you recommend this facility to anyone?:
Yes
No
Prefer Not to Answer
If you would not recommend us, please state why.:
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Please rate our website's design and ease of use.:
Superb!
Good
Adequate
Needs Improvement
Poor
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Please rate our instructions on lab kits/forms.:
They were clear, accurate, and thorough.
They were good.
They were adequate.
They need some improvement.
They were poor.
N/A
What problem(s) did you have with lab kits/forms?:
What do you like most about our services?:
Please list how our services could be improved.:
Please share any additional comments.:
Copyright 2004 Francis Holistic Medical Center, P.C., Last Modified: March 12, 2008