Date of visit
 
 
  Location
 
 
  Physician/PA/Nurse/MA
 
  Receptionist
 
 
 
  Patient Name (optional)
 
 
  Phone (optional)
 
  E-mail (optional)
 
 
 
1: The receptionist was professional, friendly and helpful.
 
 
2: The medical staff introduced themselves.
 
 
3: The medical staff was professional, friendly and helpful.
 
 
4: I was kept informed of what to expect throughout my visit.
 
 
5: The medical staff clearly explained test results and planned treatment.
 
 
6: Upon discharge I received clear instructions and my questions were answered.
 
 
7: My medical needs were met in a timely manner.
 
 
8: How would you rate our facility and accommodations?
 
 
 
9: How would you rate your overall Austin Immediate Care experience?
   
 
10: I would return to Austin Immediate Care.
       
 
11: If Austin Immediate Care were not available, how would you handle your medical emergency?
   
   
 
 
12: How did you hear about Austin Immediate Care? (Check all that apply.)
   
   
 
 
 
  Suggestions/Comments:
 
 
  Are you willing to provide a testimonial about the care you or a loved received at Austin Immediate Care for advertising purposes? If so, please write a very brief description of your experience and be sure to include your contact information above. Thank you!