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!

4	Excellent
3	Good
2	Satisfactory
1	Poor
N/A	Not Applicable

Note: All fields are required unless marked with *.

1.	Patient's Name
2.	Patient's E-mail Address
3.	Patient's Gender Male Female
4.	Patient's Date of Birth
5.	Date of Visit
6.	Patients First Visit? Yes No
7.	Clinic Location
8.	Staff courtesy, attentiveness and professionalism 4   3   2   1   N/A
9.	Clerical/ Front Office Staff 4   3   2   1   N/A
10.	Nurses, Lab Techs, and X-Ray Techs 4   3   2   1   N/A
11.	Care Provider 4   3   2   1   N/A
12.	Cleanliness and appearance of the facility 4   3   2   1   N/A
13.	Attention given to your healthcare needs by your Care Provider (Physician or Nurse Practitioner) 4   3   2   1   N/A
14.	What will be your overall assessment for today's visit 4   3   2   1   N/A
15.	Would you recommend our clinic to others? 4   3   2   1   N/A
16.	How Long was your Office Visit today? Less than an hour 1.5-2 hours 2.5-3 hours Greater than 3 hours
17.	Comments ( Please describe your experience )