Optional Personal InformationIf you would like feedback from our staff, please provide the following information.Name First Last PhoneEmail May we use your comments as a testimoninal on our website or other materials? Yes No Your first name and town will be public. Appointment InformationDate of Appointment MM slash DD slash YYYY Time of Appointment : AM PM AM/PM Which Clinic Did You Visit?Main Clinic - 2901 Medical Center DriveEast Clinic - 1601 Market DriveAppointment or Sick CallAppointmentSick CallWhich Physician/APN Did You SeeDr. Alexander J. BaltzDr. Drew DawsonDr. Brent E. HoltDr. Danny HoltHolly Tyler Brigance, APNCammie M. Sifford, APN, FNP-BCTiffany A. Baker, APNAmy DeClerk, APNPlease Answer the FollowingPlease rank from 1-5 (5 being the best)The office staff was helpful and courteous. 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) I was able to schedule an appointment in a timely manner. 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) The waiting areas were welcoming, clean, and comfortable 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) My appointment started and ended on time. 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) My doctor or APN was/were helpful and courteous 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) If applicable, How would you rate the service and professionalism of the nursing staff? 1 (very unsatisfied) 2 (unsatisfied) 3 (neutral) 4 (satisfied) 5 (very satisfied) I would recommend Pocahontas Medical Clinic to my friends and family. 1 (no) 2 (not likely) 3 (neutral) 4 (possibly) 5 (yes) General QuestionsHow long did you have to wait to be seen by a doctor/nurse? What did you like most about your visit to our office? What did you like least about your visit to our office? What can we do to make future visits better for you? We welcome your questions or comments. Δ
