Date of Visit

Name of Attending Staff

Were you seen promptly?
Yes
No. If you were not seen promptly, please explain:


Was your doctor or provider helpful?
Yes
No, please explain:


Was your doctor or provider friendly?
Yes
No, please explain:


Was your doctor or provider professional?
Yes
No, please explain:


Was your doctor or provider properly attired?
Yes
No, please explain:


Were all staff members helpful and polite?
Yes
No, please explain:

Your Normal Doctor or Provider

How would rate the quality of care you have received from Beaver Family Clinic? No Opinion Poor Fair Excellent

What is your overall satisfaction level with Beaver Family Clinic? No Opinion Poor Fair Excellent

Would you recomend Beaver Family Clinic to others?
Yes
No, please explain:


What do you like about Beaver Family Clinic?


What do you dislike about Beaver Family Clinic?


Is there anything about us that irritates you?
No
Yes, please explain:


Do you have any specific suggestions or comments for improving Beaver Family Clinic?


Your name and contact information? (optional)