Mayo

(A value is required for questions in yellow.)

When you have completed the survey, please click the yes button at the bottom of the form.

1.  How did you select our medical office?: (please select all that apply) I am a returning patient I was referred by another physician A family member or friend recommended your office Your office is close to my home I searched the internet Saw your advertisement in the newspaper / yellow pages

2.  What was the primary reason for your visit? Annual Physical Routine check up Not feeling well Referred by another physician Minor surgical procedure Diagnostic testing blood work x-rays etc Prescription refill change Follow up visit Emergency visit Accompanied a family member

For the next set of questions please select the best rating:

Please rate our service and support 1 very poor good excellent 4 outstanding 3.  How would you rate our hours of operation? 4.  How would you rate the ease of scheduling your appointment with our center? 5.  How would you rate the manner you were greeted by the receptionist and nursing staff? 6.  How well did your health care provider explain your diagnosis and treatment to you? 7.  How would you rate our facility to a friend or relative who needed medical care?

8.  If you were given a choice, would you return to our facility for your next medical visit?  Yes  No

9.  If you answered NO to the question above, is your reason for not returning due to unacceptable service at our facility?  Yes  No

10.  Comments; pls tell us more about your visit, if you would like to have someone contact you, please include your name and contact information.

Please click the YES button when you have completed this survey.