Name
*
First Name
Last Name
Which State is the clinic you visited in?
*
Illinois
Indiana
Which Illinois Location did you visit?
Archer Heights, Chicago, IL
Aurora, IL
Blue Island, IL
Bolingbrook, IL
Bourbonnais, IL
Burbank, IL
Calumet Park, IL
Carol Stream, IL
Cedar Lake, IN
Chicago Ridge, IL
Cicero, IL
Crown Point on 109th & Broadway, IN
Crown Point on Burr & 30, IN
Dyer, IN
Elmhurst on Butterfield, IL
Elmhurst on York Street, IL
Gage Park, Chicago, IL
Garfield Ridge, Chicago, IL
Griffith, IN
Griffith next to Walgreens, IN
Hammond on 5th Avenue, IN
Hammond on Sibley, IN
Hobart, IN
Lakeview, Chicago, IL
Logan Square, Chicago, IL
Lombard, IL
Matteson, IL
Mayfair, Chicago, IL
Melrose Park, IL
Merrillville, IN
Merrillville next to Walgreens, IN
Michigan City, IN
Mt. Greenwood, Chicago, IL
Munster, IN
Norridge, IL
Northbrook, IL
Portage, IN
Portage next to Walgreens, IN
Portage Park, Chicago, IL
Richton Park, IL
River Forest, IL
River North, Chicago, IL
Roscoe Village, Chicago, IL
Schererville, IN
Skokie, IL
Tinley Park on Harlem, IL
Tinley Park on LaGrange, IL
West Loop, Chicago, IL
Westmont, IL
Wheaton, IL
Wicker Park, Chicago, IL
Willowbrook, IL
Which Indiana Location did you visit?
Cedar Lake
Crown Point
Crown Point (Beacon Hill)
Dyer
Griffith
Hammond
Hobart
Merrillville
Michigan City
Munster
North Hammond
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 provide a good callback number.
Please provide the patient's full name.
What is the date of birth?
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