Patient's first name
*
Which State is the clinic you visited in?
*
Illinois
Indiana
Which Illinois Location did you visit?
Blue Island
Bourbonnais
Calumet Park
Gage Park, Chicago
Lakeview, Chicago
Mt. Greenwood, Chicago
River Forest
River North, Chicago
Roscoe Village, Chicago
Skokie
West Loop, Chicago
Wicker Park, Chicago
Willowbrook
Which Indiana Location did you visit?
Cedar Lake
Crown Point
Dyer
Hammond
Merrillville
Munster
Portage
Schererville
When did you visit our clinic?
*
-
Month
-
Day
Year
Date
Were you pleased with your overall experience at our clinic?
Yes
No
Unsure
Was the Front Desk Staff polite and helpful?
Yes
No
Unsure
How long was your overall wait time?
Less than 15 minutes
15-30 minutes
30-45 minutes
45-60 minutes
Longer than 60 minutes
Were you satisfied with your overall wait time?
Yes
No
Unsure
Would you return for additional care if needed?
Yes
No
Unsure
Would you recommend us to your family and friends?
Yes
No
Unsure
Was your provider sensitive to your needs?
Yes
No
Unsure
Do you feel your provider listened to you?
Yes
No
Unsure
Who was your provider?
Suggestions on any services you would like us to offer.
Suggestions on how we can improve our services.
Any additional comments you would like to share with us.
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If you would like to be contacted regarding your experience, please list your contact info below.
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