Please enter the information requested and then click on the "Submit" button. The fields marked with * are required. On your last visit you saw? Doctor Dentist Lab Social Worker WIC How do you feel about... The way you were treated by the staff? Great Good Fair Poor Doesn't Apply to my visit The amount of time the doctor/dentist spent with you? Great Good Fair Poor Doesn't Apply to my visit The time it took you to see the doctor/dentist? Great Good Fair Poor Doesn't Apply to my visit The amount of time the doctor/dentist spent with you? Great Good Fair Poor Doesn't Apply to my visit The way things were explained to you? Great Good Fair Poor Doesn't Apply to my visit The caring and professional attitude of the staff? Great Good Fair Poor Doesn't Apply to my visit The cleanliness of the clinic? Great Good Fair Poor Doesn't Apply to my visit Who did you see on your last visit?Give the doctor/dentist's name Would you recommend this clinic to family and friends? Great Good If no, why? Was this your first visit to our clinic? Yes No Payments Yes No Were You Informed of the Sliding Fee Discount Policy? Did you qualify for the Sliding Fee Discount? Did you Pay your Discount Nominal fee? Has the sliding fee scale created any financila barrier to care? Email Please leave any other comments you may have
