Rural Clinic Healthcare Service Quality Survey
Help us improve our healthcare services by sharing your experience at our rural clinic. Your responses are confidential and will be used to enhance the quality of care.
Please provide your full name (optional):
First Name
Last Name
How old are you?
*
What is your gender?
*
Female
Male
Non-binary
Prefer not to say
When was your most recent visit to the clinic?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What was the main reason for your visit?
*
Please Select
Routine check-up
Vaccination
Acute illness
Chronic disease management
Maternal/child care
Other
Please rate the following aspects of your clinic experience:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Cleanliness of the facility
1
2
3
4
5
Professionalism of staff
6
7
8
9
10
Friendliness of staff
11
12
13
14
15
Communication and explanations
16
17
18
19
20
Waiting time
21
22
23
24
25
Privacy and confidentiality
26
27
28
29
30
How satisfied are you with the overall quality of care you received?
*
1
2
3
4
5
Did you feel your health concerns were adequately addressed during your visit?
*
Yes
No
Would you recommend this clinic to others?
*
Yes
No
Not sure
Please share any suggestions or comments to help us improve our services:
Submit Survey
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