Patient Exit Survey
Please take a moment to complete this survey before leaving. Your feedback is important to us.
Overall, how satisfied were you with the care you received today?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Please rate your experience on a scale of 1-5 (1 being the lowest and 5 being the highest):
1
2
3
4
5
Was the staff friendly and attentive?
Yes
No
Not sure
Other
Please provide any additional feedback or comments:
Submit
Should be Empty: