Patient Survey

We'd love to hear your thoughts about our clinic and how we can help better serve you. Please fill out the survey form below...thank you!

Please provide your contact info:

Name*

First Last

Phone Number*

Please tell us how you found out about Premier Urgent Care :*

Do you have a regular family doctor?*

Yes
No

If Premier Urgent Care was not here, where would you have gone for treatment? :*

Emergency Room
Family Doctor
Would have had no treatment
Other

Which location did you visit?*

Alexandria
Pineville
Jena

What was your date of visit?*

Have you previously visited this location of Premier Urgent care?*

Yes
No

How would you rate:

Overall quality of medical care?*

Excellent
Good
Fair
Poor

Courtesy and helpfulness of front desk staff?*

Excellent
Good
Fair
Poor

Courtesy and professionalism of Nursing staff?*

Excellent
Good
Fair
Poor

During your visit were you periodically informed of the status of your treatment and offered water or other conveniences?*

Yes
No

Based on your recent appointment, how would you rate your PROVIDER -Listens to you*

Excellent
Good
Fair
Poor

Takes Enough Time with you*

Excellent
Good
Fair
Poor

Explains your Plan of Care*

Excellent
Good
Fair
Poor

Satisfaction with your Plan of Care.*

Excellent
Good
Fair
Poor

Cleanliness and neatness at Premier Urgent Care?*

Excellent
Good
Fair
Poor

Clear communication and instructions during visit?*

Excellent
Good
Fair
Poor

How would you rate your WAIT TIME IN -Waiting Room*

Excellent
Good
Fair
Poor

Exam Room*

Excellent
Good
Fair
Poor

Was the cost of your visit reasonable?*

Yes
No

How likely would you be to refer to friends & relatives?*

Very Likely
Somewhat Likely
Somewhat Unlikely
Not at all Likely

Overall, how would you rate your Experience?*

Excellent
Good
Fair
Poor

Overall, were you satisfied enough to return to our center for medical care in the future?*

Yes
No

Would you be willing to share your experience in Premier Urgent Care marketing initiatives?*

Yes
No

What was the date of your visit?*

We’d like to hear any comments you might have about your visit to our clinic.*

To improve our services and better serve our clients, we may wish to contact you regarding your feedback. What is your e-mail address?

(Note that your e-mail address will only be used to contact you if appropriate and will not be used for any other purpose.) :

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