Patient Survey :: Velocity Care :: Urgent Treatment Center

We'd love to hear your thoughts about our clinic and how we can help better serve you. Please fill out the survey form below...thank you!

Please provide your contact info:

First Name:

Last Name:

Phone Number:

Please tell us how you found out about the Urgent Care Center:

Do you have a regular family doctor? Yes No

If the Urgent Care Center were not here, where would you have
gone for treatment?

Emergency room

Family doctor

Would have had no treatment

Other

How would you rate:	Poor	Fair	Good	Excellent
Overall quality of medical care?
Courtesy and helpfulness of front desk staff?
Courtesy and professionalism of medical staff?
Cleanliness and neatness of Urgent Care Center?
Overall visit time?
Clear communication and instructions during visit?

Was your waiting time before being seen by a physician acceptable?			Yes No

Have you previously visited Velocity Care?			Yes No

Was the cost of your visit reasonable?			Yes No

Overall, were you satisfied enough to return to our center for medical care in the future?			Yes No

What was the date of your visit?

We’d like to hear any comments you might have about your visit to our center.

To improve our services and better serve our clients, we may wish to contact you regarding your feedback. What is your e-mail address? (Note that your e-mail address will only be used to contact you if appropriate and will not be used for any other purpose.)

To further investigate your feedback, what is your Patient Account #? (Optional - This is located in the upper left hand corner of your discharge form.)

Input text from image below.



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