clickguardian

Patient Feedback Form

Home / Patient Feedback Form

We would like your honest feedback. Kindly take a few minutes to give your feedback. Please answer these questions either yes or no about the visit you had today. Think about a specific provider or staff member – for example, your doctor or nurse – when answering.

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

9a. Did this provider or staff member give you instructions about what to do to take care of this illness or health condition?
YesNo

9b. Were these instructions easy to understand?
YesNo

9c. Did this provider or staff member ask you to describe how you were going to follow these instructions?
YesNo

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

WhatsApp WhatsApp us