Clinic Doctor Visit Survey

This form was translated to Would you like to see the original form instead ?

Value entered in element () already exists !

Doctor visit survery

* is mandatory field

Full Name

Last Name

Phone

Area

Local

Local

Email

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

-- Select country --

Please Circle One

Please Circle One

Please Select	No	Sometimes	Usually	Always
1. I trust this doctor	1. I trust this doctor No No	1. I trust this doctor Sometimes Sometimes	1. I trust this doctor Usually Usually	1. I trust this doctor Always Always
2. This doctor explains things in words I understand	2. This doctor explains things in words I understand No No	2. This doctor explains things in words I understand Sometimes Sometimes	2. This doctor explains things in words I understand Usually Usually	2. This doctor explains things in words I understand Always Always
3. This doctor treats me with respect	3. This doctor treats me with respect No No	3. This doctor treats me with respect Sometimes Sometimes	3. This doctor treats me with respect Usually Usually	3. This doctor treats me with respect Always Always
4.This doctors listens well	4.This doctors listens well No No	4.This doctors listens well Sometimes Sometimes	4.This doctors listens well Usually Usually	4.This doctors listens well Always Always
5. This doctor lets me make choices about my treatment	5. This doctor lets me make choices about my treatment No No	5. This doctor lets me make choices about my treatment Sometimes Sometimes	5. This doctor lets me make choices about my treatment Usually Usually	5. This doctor lets me make choices about my treatment Always Always
6.This doctor makes sure I can afford my medical care	6.This doctor makes sure I can afford my medical care No No	6.This doctor makes sure I can afford my medical care Sometimes Sometimes	6.This doctor makes sure I can afford my medical care Usually Usually	6.This doctor makes sure I can afford my medical care Always Always

Comments

*

I agree to the TERMS AND CONDITIONS

Owner: Waiting for owner info...

Hi there, do you need any assistance?

Click to open chat