Patient Feedback Form

1. Were you treated in a professional and courteous manner by the First Response staff ?
YesNo

2. Was your waiting time to see the doctor acceptable? (FOR DOCTOR ON CALL SERVICES – LEAVE EMPTY IF OTHER SERVICES)
YesNo

3. Did this provider or staff member explain things in a way that was easy to understand?
YesNo

4. Did this provider or staff member use medical words you did not understand?
YesNo

5. Was this provider or staff member warm and friendly?
YesNo

6. Did this provider or staff member listen carefully to you?
YesNo

7. Did this provider or staff member encourage you to ask questions?
YesNo

8. Did this provider or staff member answer all your questions to your satisfaction?
YesNo

9. Did you see this provider or staff member for a specific illness or for any health condition?
YesNo

10. Would you recommend First Response team to your family and Friends?
YesNo