Patient Experience

	Family, Friend or Coworker
	Physician Referral
	Insurance
	Location
	Advertising/Media Interviews (Ads, Television, Radio)
	Phone book
	Website
	Other

Did you have enough time to address issues, questions, and concerns with your physician?

	Yes
	No

Please select the location where you had your patient visit:

Please select a location Advanced Aesthetics Andover Augusta Bethel-Newton Carriage Park Derby Eberly Farm Founders' Circle Murdock Northeast Sleep Medicine Center (East) Sleep Medicine Center (West)

	Poor		Fair		Good		Very Good		Excellent
Hours of Operation
Phone Service
Accommodations (cleanliness, comfort...)
Physician or Provider (PA, ARNP)
Level of skill
Personal manner (courtesy, respect…)
Information provided/complete responses
Nursing Staff
Level of skill
Personal manner (courtesy, respect…)
Information provided/complete responses
Other Staff (Lab, Pharmacist)
Level of skill
Personal manner (courtesy, respect…)
Information provided/complete responses
Office Staff (Receptionist, Patient Registration)
Personal manner (courtesy, respect…)
Information provided/complete responses
Overall Visit

Would you recommend Wichita Clinic to a family, friend or coworker?

	Yes
	No

Please explain why you would or would not recommend Wichita Clinic.

Additional comments, compliments or concerns about your experience at Wichita Clinic?