Feedback Survey

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In order to continuously improve our clinic, please take a few minutes to answer some questions. This will help us to make changes to our clinic to better serve you.

Please answer the questions to reflect your overall impression of Champions Urgent Care …not just today’s visit.

We appreciate your time to help us.

1. How do you rate the convenience of the clinic’s location?
Very PoorPoorAverageGoodVery GoodExcellent

2. How do you rate the clinic’s hours of operation?
Very PoorPoorAverageGoodVery GoodExcellent

3. What length of time did you wait to be seen?
No Wait10 minutes20 minutes30 minutesOver 30 minutes

Do you find this to be:

AcceptableUnacceptable

4. Please rate the cleanliness and appearance of the:
Waiting Room:
Very PoorPoorAverageGoodVery GoodExcellent

Exam Room:
Very PoorPoorAverageGoodVery GoodExcellent

5. Please rate your experience during this visit with any of the following staff with whom you have interacted:
Front Desk:
Very PoorPoorAverageGoodVery GoodExcellent

DR/NP/PA:
Very PoorPoorAverageGoodVery GoodExcellent

6. During your visit in the exam room, how do you rate:
How thoroughly the healthcare professional asked about your symptoms and how you are feeling?
Very PoorPoorAverageGoodVery GoodExcellent

How the healthcare professional listened to you?
Very PoorPoorAverageGoodVery GoodExcellent

How the healthcare professional explained treatment/diagnosis to your satisfaction?
Very PoorPoorAverageGoodVery GoodExcellent

The amount of time the healthcare professional spent with you?
Very PoorPoorAverageGoodVery GoodExcellent

The healthcare professional’s bedside manner?
Very PoorPoorAverageGoodVery GoodExcellent

7. After your visit, did you generally feel you understood how to take care of your problem or illness?
YesNo

8. Overall, how would you rate your visit to Champions Urgent Care?
Very PoorPoorAverageGoodVery GoodExcellent

9. How likely are you to recommend our clinic to people you know?
Not LikelySlightly LikelyModerately LikelyVery LikelyExtremely Likely

Other comments/suggestions: