We would like to know how you feel about the services we provide so we can make sure we are meeting your needs and exceeding your expectations.  Your responses are valuable and are directly responsible for improving our services.  All responses will be kept confidential and anonymous.  We appreciate your time and the opportunity to care for your family.

Please check how well you think we are doing in the following areas.
Strongly Agree
Agree
Uncertain Unsure
Disagree
No Opinion Does Not Apply
1. During this visit my doctor treated me with courtesy and respect.
2. During this visit my doctor listened carefully to me.
3. I would recommend this doctor to my friends and family.

Always
Almost Always
Usually
Sometime
Almost Never
Never
Does Not Apply
4. When you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed?

5. Using any number from 0 to 10 in the pull down menus, where 0 is the worst doctor possible and 10 is the best doctor possible, what number would you use to rate the doctor that you saw today?
Dr. Teresa Salter
Dr. David Horowitz
Dr. William Adams
Dr. Irene Chao
Dr. Samantha Baer
Dr. Mary E. Capps

6. Please tell us about anything that was done well or anything that could have improved the care and services you received at your most recent visit. Use the space below.

7. Please provide your email address. (optional)


Review the above information for accuracy before submitting.