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Patient Satisfaction Survey

1. Name? (only required if you want to enter to win a $200 Visa gift card)

2. How would you rate PromptMed Urgent Care in the following areas?

Space Cell	Highly Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Highly Dissatisfied
Overall Experience	Overall Experience: Highly Satisfied	Overall Experience: Somewhat Satisfied	Overall Experience: Neutral	Overall Experience: Somewhat Dissatisfied	Overall Experience: Highly Dissatisfied
Front Desk Staff	Front Desk Staff: Highly Satisfied	Front Desk Staff: Somewhat Satisfied	Front Desk Staff: Neutral	Front Desk Staff: Somewhat Dissatisfied	Front Desk Staff: Highly Dissatisfied
Doctors/ Practitioners	Doctors/ Practitioners: Highly Satisfied	Doctors/ Practitioners: Somewhat Satisfied	Doctors/ Practitioners: Neutral	Doctors/ Practitioners: Somewhat Dissatisfied	Doctors/ Practitioners: Highly Dissatisfied
Medical Assistants	Medical Assistants: Highly Satisfied	Medical Assistants: Somewhat Satisfied	Medical Assistants: Neutral	Medical Assistants: Somewhat Dissatisfied	Medical Assistants: Highly Dissatisfied
Speed of Service	Speed of Service: Highly Satisfied	Speed of Service: Somewhat Satisfied	Speed of Service: Neutral	Speed of Service: Somewhat Dissatisfied	Speed of Service: Highly Dissatisfied

3. How Likely are you to recommend PromptMed Urgent Care to a friend or family member?

4. How did you hear about PromptMed Urgent Care (select all that apply)?

5. Please provide any additional feedback on what made your recent experience great, or what we can improve to serve you better? Note: this is not a secure or confidential form and is not intended for medical communications.