Patient Experience Survey

TODAY DATE

DATE OF LAST VISIT

IF YOU DON'T REMEMBER YOUR LAST VISIT PLEASE GIVE AN APPROXIMATE MONTH AND YEAR

LOCATION OF LAST VISIT

WHO WAS YOUR LAST DOCTOR

FIRST NAME

LAST NAME

TSCHC fees are affordable and will not keep you from returning to our clinic

Our ability to have you seen by the provider within 20 minutes of your appointment

If you applied for assistance (i.e. you qualified for a program to help pay for your care such as MHLA), was the staff helpful?

Nurse / Assistant ability to keep you informed of delays once in the waiting room

Someone from the clinic provided you the necessary tools to maintain health at home

Care provider's efforts to include you in decisions about your treatment

Additional comments or suggestions (please use this space below)

Would you like to be contacted regarding this comment? If no, we respect your wishes and will not contact you regarding this matter.

Yes No

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