INSTRUCTIONS: Please rate the following services while visiting AFC. Select the number that best represents your feelings. If a question does not pertain to you, select N/A. Thanks for your help!

5	Very Good
4	Good
3	Fair
2	Poor
1	Very Poor
N/A	Not Applicable

Note: All fields are required unless marked with *.

Patient's Name
Patient's E-mail Address
Patient's Gender Male Female
Patient's Date of Birth
Date of Visit
AFC Location Airport/SchillingerAlabasterAlcoa - Opening Fall 2013Corporate OfficeCullman - Opening Summer 2013DaphneDecaturDothanEastchaseFairhopeFestival CentreFlintridgeForestdaleGardendaleGovernor’s HouseGreystoneHampton CoveHomewoodHooverIndian LakeMadisonMontclairNashville WestOrange BeachPace Opening Fall 2013ParkwayPelhamPell CityPradoPrattvilleProvidenceSaralandSmyrnaSouthern Hills - Opening Summer 2013The GroveTiger TownTillman's CornerTrussvilleTuscaloosaUniversity DriveVestavia HillsWhitesburgWindward
Physician's Name
Please Rate The Following
1.	Courtesy and professionalism of clerical/front office staff 5   4   3   2   1   N/A
2.	Courtesy and professionalism of nurses, lab techs, and x-ray techs 5   4   3   2   1   N/A
3.	Courtesy and professionalism of care provider (physician or nurse practitioner) 5   4   3   2   1   N/A
4.	Cleanliness and appearance of the facility 5   4   3   2   1
5.	Attention given to your healthcare needs by your care provider 5   4   3   2   1   N/A
6.	Overall assessment of your visit 5   4   3   2   1   N/A
7.	Likelihood to recommend our clinic to others 5   4   3   2   1   N/A
8.	How did you hear about AFC? TV Internet Word of Mouth Yellow Pages Location Other
9.	Did anyone inform you about U-Save Pharmacy (Birmingham and Huntsville only)? Yes No Does Not Apply
10.	Did anyone inform you about our other services: WeighToLive and Specialty Services (Birmingham Area only)? Yes No Does Not Apply
11.	Please feel free to write any additional comments that you feel might help us improve our service.
12.	May an AFC manager contact you to discuss your care? Yes No
13.	Patient's Phone Number