Greater Mobile Urgent Care

Rate the following:

Poor

Fair

Good

Excellent

Overall quality of medical care?

Courtesy and helpfulness of front desk staff?

Courtesy and professionalism of medical staff?

Cleanliness and neatness of Urgent Care Center?

Overall visit time?

Clear communication and instructions during visit?

Was your waiting time before being seen by a physician acceptable?

Yes No

Have you been to our center before?

Yes No

If this is your first visit, please tell us how you found out about us.
Family / Friend	Workplace	Doctor referral
Internet search	Newspaper	Billboard
Television	E-mail	Direct mail
Radio	Web site	Other:

Do you have a regular family doctor? Yes No

If the Urgent Care Center were not here, where would you have gone for treatment?

Emergency room

Family doctor

Would have had no treatment

Other

Was the cost of your visit reasonable? Yes No

Overall, were you satisfied enough to return to our center for medical care in the future?

Yes No

We’d like to hear any comments you might have about your visit to our center.

To improve our services and better serve our clients, we may wish to contact you regarding your feedback.What is your e-mail address?

(Your e-mail address will only be used to contact you if appropriate and will not be used for any other purpose.)

To further investigate your feedback, what is your Patient Account #? (optional)
(This is located in the upper left hand corner of your discharge form.)

Date of service: