Fox Valley Women & Children's Health Partners Patient Survey
RequiredRequired Question(s)
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1.
When was the last date of your visit?
 

50 characters left.
2.
Was this your first visit to FVWCHP?
Yes
No
Required 3.
Were you here for Women's Health or Pediatrics?
Women's Health
Pediatrics
Required 4.
How many minutes did you wait after your scheduled appointment time before you were called to the exam room?
0-5 Minutes
5-10 Minutes
10-15 Minutes
15+ Minutes
Required 5.
How many minutes did you wait in the exam room before  you were seen by a doctor or Nurse Practitioner (NP)?
0-5 Minutes
5-10 Minutes
10-15 Minutes
15+ Minutes
Required 6.
What is your overall assessment of your appointment at FVWCHP?
 Poor Fair Good Very Good Excellent 
Overall cheerfulness of our practice
Overall cleanliness of our practice
Overall rating of care received during your visit
Convenience of our office hours
Our sensitivity to your needs
Our concern for your privacy
7.
Ease of obtaining test results:
Easy Difficult          
         
8.
Please describe your overall experience at FVWCHP:
 

350 characters left.
9.
What could we do better?
 

350 characters left.
10.
If you would like to submit a testimonial or a comment that we can post on our website or Facebook, please leave it here:
 

350 characters left.
11.
Optional Information

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First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
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