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Client Survey

Please note: Florida has a very broad public records law. Electronic communications such as this survey is available to the public and media upon request. If you do not want your name released then do not complete that section. Phone calls and letters are treated confidentially.

Site Location:      Date:      Name: (optional) 

  Yes No
1. Is this your first visit to the clinic?  
2. Did you have an appointment? 
3. Did you have trouble getting an appointment?
4. Was this a good time for your appointment?

 If no, Why? 

5. Did you arrive within 15 minutes of your appointment time?  Yes  No

6. What type of clinic services did you come in for today?  

Child Health   Immunizations    Family Planning    Physician Services    Smoking    Diabetes    Classes    Pregnancy

Other

7. How long did you wait before initially being seen for service?  

8. Did you find our facility clean?   Yes    No      If no, what area was not clean?

9. Were your questions answered?   Yes    No

10. How would you rate the service you received?

  Excellent Good Okay Poor Does Not Apply
Clerks
Nurses
Physician / Doctor / ARNP
Laboratory Technicians
WIC
Other

11. Was your privacy respected?   Yes    No

12. Please rate our overall performance:   Excellent    Good    Okay    Poor

13. How can we serve you better?

14. Is there any staff member you would like to comment about?

To submit your survey, enter the number you see in the box and click submit below.