Apollo Urgent Care - Patient Experience Survey

Please rate us on the following: *
Please rate us on the following:	Very Unsatisfied	Unsatisfied	Neutral	Satisfied	Very Satisfied
Cleanliness of the clinic	Cleanliness of the clinicVery Unsatisfied	Cleanliness of the clinicUnsatisfied	Cleanliness of the clinicNeutral	Cleanliness of the clinicSatisfied	Cleanliness of the clinicVery Satisfied
Comfort and safety in waiting area	Comfort and safety in waiting areaVery Unsatisfied	Comfort and safety in waiting areaUnsatisfied	Comfort and safety in waiting areaNeutral	Comfort and safety in waiting areaSatisfied	Comfort and safety in waiting areaVery Satisfied
Availability of appointment times convenient to you	Availability of appointment times convenient to youVery Unsatisfied	Availability of appointment times convenient to youUnsatisfied	Availability of appointment times convenient to youNeutral	Availability of appointment times convenient to youSatisfied	Availability of appointment times convenient to youVery Satisfied
Clinic location convenience	Clinic location convenienceVery Unsatisfied	Clinic location convenienceUnsatisfied	Clinic location convenienceNeutral	Clinic location convenienceSatisfied	Clinic location convenienceVery Satisfied
Waiting time before you checked-in	Waiting time before you checked-inVery Unsatisfied	Waiting time before you checked-inUnsatisfied	Waiting time before you checked-inNeutral	Waiting time before you checked-inSatisfied	Waiting time before you checked-inVery Satisfied
Waiting time in the exam room before a doctor saw you	Waiting time in the exam room before a doctor saw youVery Unsatisfied	Waiting time in the exam room before a doctor saw youUnsatisfied	Waiting time in the exam room before a doctor saw youNeutral	Waiting time in the exam room before a doctor saw youSatisfied	Waiting time in the exam room before a doctor saw youVery Satisfied
Friendliness/courtesy of the staff towards you	Friendliness/courtesy of the staff towards youVery Unsatisfied	Friendliness/courtesy of the staff towards youUnsatisfied	Friendliness/courtesy of the staff towards youNeutral	Friendliness/courtesy of the staff towards youSatisfied	Friendliness/courtesy of the staff towards youVery Satisfied
Staff working together to care for you	Staff working together to care for youVery Unsatisfied	Staff working together to care for youUnsatisfied	Staff working together to care for youNeutral	Staff working together to care for youSatisfied	Staff working together to care for youVery Satisfied
Your confidence in this care provider (doctor)	Your confidence in this care provider (doctor)Very Unsatisfied	Your confidence in this care provider (doctor)Unsatisfied	Your confidence in this care provider (doctor)Neutral	Your confidence in this care provider (doctor)Satisfied	Your confidence in this care provider (doctor)Very Satisfied
Provider (doctor) listening to your concerns	Provider (doctor) listening to your concernsVery Unsatisfied	Provider (doctor) listening to your concernsUnsatisfied	Provider (doctor) listening to your concernsNeutral	Provider (doctor) listening to your concernsSatisfied	Provider (doctor) listening to your concernsVery Satisfied
Your overall appointment experience	Your overall appointment experienceVery Unsatisfied	Your overall appointment experienceUnsatisfied	Your overall appointment experienceNeutral	Your overall appointment experienceSatisfied	Your overall appointment experienceVery Satisfied

Would you recommend us to your family and/or friends?

Would you recommend us to your family and/or friends? Yes Maybe No
Patient Gender

Patient Gender Male Female
Patient Age (in Years)

Patient Age (in Years) Less than 20 21 to 30 31 to 45 46 to 55 55 to 69 70 or more
Patient Ethinicity
If you have concerns with your experience today, can we contact you?

If you have concerns with your experience today, can we contact you? Yes No

Our practice owner can contact you. This will be kept confidential.
Phone number to be reached at Phone number to be reached at * - ### - ### ####
Name Name First Last
Any comments

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