Form

Patient's Age*
Patient's Sex*

Male Female
Date of Visit*
- Month - Day Year
at
/ Hour Minutes
Name of Physician that took care of you:*
Time of Day you arrived at Guardian Urgent Care:*

8 a.m. - 12 p.m. 12 p.m. - 4 p. m. 4 p.m. - 8 p.m.
Why did you Visit Guardian Urgent Care?*

Illness Injury x-ray drug screen other lab test physical (work/school/wellness)
If you answered Injury to the previous question was it work related?

Yes No
How did you hear about Guardian Urgent Care?*
If you answered advertisement to the previous question, where did you see our ad?
If you answered employer to the previous question, who is your employer?
If you answered recommended by another medical provider, what is the name of the provider or Medical Practice?
Please rate Guardian Urgent Care in the following areas:
Hours of Operation*

Excellent Very Good Good Fair Poor Does Not Apply
Services Offered*

Excellent Very Good Good Fair Poor Does Not Apply
Convenience of Location*

Excellent Very Good Good Fair Poor Does Not Apply
Front Desk Staff was Friendly and Knowledgeable*

Excellent Very Good Good Fair Poor Does Not Apply
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Time spent in Waiting Room*

Excellent Very Good Good Fair Poor Does Not Apply
Time spent in Exam Room*

Excellent Very Good Good Fair Poor Does Not Apply
Medical Staff was friendly and knowledgeable*

Excellent Very Good Good Fair Poor Does Not Apply
Physician listened to you and answered all questions*

Excellent Very Good Good Fair Poor Does Not Apply
Level of Treatment by the Physician*

Excellent Very Good Good Fair Poor Does Not Apply
Time spent waiting for Laboratory Samples*

Excellent Very Good Good Fair Poor Does Not Apply
Pricing for Services*

Excellent Very Good Good Fair Poor Does Not Apply
Charges were explained*

Excellent Very Good Good Fair Poor Does Not Apply
Overall Cleanliness of the Facility*

Excellent Very Good Good Fair Poor Does Not Apply
Overall Comfort during your visit*

Excellent Very Good Good Fair Poor Does Not Apply
Overall Quality of Care*

Excellent Very Good Good Fair Poor Does Not Apply
Would you recommend Guardian Urgent Care to Others?*

Yes Maybe No Never
Why did you choose Guardian Urgent Care over other Hospitals/Medical Facilities?:*
What suggestions and/or comments do you have for Guardian Urgent Care so that we may strive for excellence:*
May we use your comments on our website, flyer, or any other publication produced by Guardian Urgent Care?

Yes No
Email Address:
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