1.  What type of patient are you?
3.  How was the appointment availability?
2.  What office do you visit?
4.  How would you rate the reception desk staff?
5.  How long did you wait in the waiting room before you were seen by a staff member?
6.  How would you rate the nurse/technician concern for your condition?

8.  Do you feel the doctor's explanation of your condition and treatment was clear?.
7.  How would you rate the nurse/technicians friendliness?
9.  How would you rate your overall experience at Dr. Jacey's office?
10.  Would you recommend Dr. Jacey to a friend or relative?
We care about your opinion! Please take some time to let us know how we are doing.
First VisitEstablished
ImmediateLess than 1 week
RichmondNorthern Neck
Longer than 1 weekLonger than 2 weeks
FriendlyAdequateRude
0-5 min5-20 min20-40 minover 40 min
Very helpfulHelpfulFairNeeds Improvement
YesNo
FriendlyAdequateRude
ExcellentGoodAdequateNeeds ImprovementPoor
YesNo