Clinic Services Survey

 

Clinic Name:
Date of Visit:

1 = Met needs Exceptionally       3= Needs Met        5= Needs Not Met
  1 2 3 4 5
Promptness of obtaining an appointment
Cost
Wait time while in clinic
Quality and thoroughness of services provided
Staff courtesy
DirectNet case managers
           
Suggestions on how service might be improved in future:

 

 
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