Feedback

Feedback Form

Your Name

Date of Visit

Did you find the atmosphere of the clinic pleasant?

[checkbox* checkbox-pleasant exclusive "Yes" "No"]

If No, please tell us why:

Were you taken to the consultation room in a reasonable length of time?

[checkbox* checkbox-time exclusive "Yes" "No"]

If No, please tell us why:

Were you treated with courtesy and respect by the clinic staff?

[checkbox* checkbox-courtesy exclusive "Yes" "No"]

If No, please tell us why:

Would you return to this clinic again?

[checkbox* checkbox-return exclusive "Yes" "No"]

If No, please tell us why:

Would you like to get feedback about your questions or concerns?

[checkbox* checkbox-feedback exclusive "Yes" "No"]

If No, please tell us why:

If Yes, please leave your contact here:

Overall Experience

If you checked “opportunity for improvement” please tell us more:


This form is of communication is for patient experience feedback and comments. Feedback and comments are checked periodically by the clinic management. No doctor, nurse or medical office assistant will check this message.

Do not submit or request the following as these e-mails cannot be answered:

  • Emergencies – PLEASE CALL 911

  • Medical – Requests, Information – Lab reports or Test Results, and Disclosure

  • Appointments booking, canceling, or rescheduling.

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