Care Station appreciates your time and effort in completing this survey. Your honest comments will help us to improve our services. This form is for the use of Care Station patients only.

Date of visit
Office visited
Was this your first visit?
Did you have an appointment?
Patient's sex

Access to Care

How many minutes did you wait in the waiting room before you were called to register?
How many minutes did you wait before being ushered to an examination room?

Please rate the service you received. Check the box that best describes your experience. Additional comments are welcome below.

  Poor Fair Good Excellent N/A
1. Courtesy of registration person
2. Speed of the registration process
3. Length of wait time before going into an exam room
4. Courtesy of clinical staff
5. Cleanliness and comfort of exam room
6. Courtesy of doctor/PA
7. Ability of doctor/PA to answer your questions
8. Demonstration of care and concern by the staff for your worries
9. Instructions given to you for follow up care
10. Amount of time care provider spent with you
11. Concern for your privacy
12. Convenience of our office hours
13. Convenience of our office locations
14. Likelihood of you recommending our practice to others
15. Overall rating of your visit

If you would like us to respond to your evaluation, please submit a name and phone number.

Patient's Name
Telephone Number