Hailey Medical Clinic

YOUR OPINION IS IMPORTANT TO US
The Physicians and Employees have a strong commitment to providing quality healthcare in a timely and courteous manner. We rely on your feedback to let us know how we are doing in providing services to you and your family. Please take a few minutes to complete the following questions. Thank you!

1. Were you treated with courtesy and respect by the:

Receptionist/Check-in	Yes No N/A
Phone Operator	Yes No N/A
Cashier/Checkout	Yes No N/A
Nurse	Yes No N/A
Physician	Yes No N/A
Billing Staff	Yes No N/A

2. Were you treated promptly by the:

Receptionist/Check-in	Yes No N/A
Phone Operator	Yes No N/A
Cashier/Checkout	Yes No N/A
Nurse	Yes No N/A
Physician	Yes No N/A
Billing Staff	Yes No N/A

3. How would you rate the physical appearance of the clinic?

Excellent Very Good Average Below Average Poor

4. How would you rate the overall care you received?

Excellent Very Good Average Below Average Poor

COMMENTS/SUGGESTIONS:
(Max chars. 500)