Select *Which facility were you seen at? (required)Cairo DentalCairo Diagnostic CenterCairo MegaclinicCarmi Community HealthCenterCarmi DentalCedar Court ClinicHardin County Dental ClinicHardin County MedicalHarrisburg Community Health CenterPope County ClinicPulaski ClinicTamms Community Health CenterAppointment Type *Walk-InScheduledNature of Service *MedicalDentalService Utilized (required) *MedicalDentalDate of Visit (required) *Age (required) *Select *Gender (required)FemaleMalePrefer not to discloseSelect *Race / Ethnicity (required)American Indian / Alaska NativeAsianBlack / African AmericanHispanic or Latino (all races)Pacific IslanderPrefer not to discloseUnknown / OtherWhite (not Hispanic or Latino)Ease of Getting CareAbility to get in and be seenGreatGoodOKFairPoorHours Center is OpenGreatGoodOKFairPoorConvenience of Center's LocationGreatGoodOKFairPoorPrompt Return on Telephone CallsGreatGoodOKFairPoorWaiting TimeTime in Waiting RoomGreatGoodOKFairPoorTime in Exam RoomGreatGoodOKFairPoorTime Waiting for Tests to be PerformedGreatGoodOKFairPoorTime for Test ResultsGreatGoodOKFairPoorStaffProviders (Physician, Dentist, Physician Assistant, Nurse Practitioner)Listens to MeGreatGoodOKFairPoorSpends Enough Time with MeGreatGoodOKFairPoorExplains What I Want and/or Need to KnowGreatGoodOKFairPoorGives Good Advice and/or TreatmentGreatGoodOKFairPoorStaffNurses and Medical AssistantsFriendly and helpful to youGreatGoodOKFairPoorAnswer my questionsGreatGoodOKFairPoorStaffAll OthersFriendly and helpful to youGreatGoodOKFairPoorAnswer my questionsGreatGoodOKFairPoorPayment ProcessWhat you pay isGreatGoodOKFairPoorExplanation of ChargesGreatGoodOKFairPoorCollection of Payment/Money (Rate Us)GreatGoodOKFairPoorFacilityNeat and Clean BuildingGreatGoodOKFairPoorEase of Finding Where to GoGreatGoodOKFairPoorComfort and Safety While WaitingGreatGoodOKFairPoorPrivacyGreatGoodOKFairPoorConfidentialityKeep My Personal Information PrivateGreatGoodOKFairPoorHow likely are you to refer us to your friends and family?GreatGoodOKFairPoorDo you consider this center to be your regular source of care?GreatGoodOKFairPoorFeedbackWhat do you like best about our center?What do you like least about our center?Suggestions for Improvement?Additional Comments/MessageContactWould you like to be contacted to further discuss your experience?NoYesNamePhoneEmail AddressContact PreferenceCall / PhoneEmailWhich method do you preferred to be contacted by?Submit Survey
