Patient Survey
Optional Personal Information
If you would like feedback from our staff, please provide the following information.
Name
First
Last
Phone
Email
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 Information
Date of Appointment
MM slash DD slash YYYY
Time of Appointment
:
AM
PM
AM/PM
Which Clinic Did You Visit?
Main Clinic - 2901 Medical Center Drive
East Clinic - 1601 Market Drive
Appointment or Sick Call
Appointment
Sick Call
Which Physician/APN Did You See
Dr. Alexander J. Baltz
Dr. Drew Dawson
Dr. Brent E. Holt
Dr. Danny Holt
Holly Tyler Brigance, APN
Cammie M. Sifford, APN, FNP-BC
Tiffany A. Baker, APN
Amy DeClerk, APN
Please Answer the Following
Please 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 Questions
How 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.
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