1. Date and Time of visit:
2. Name of the provider:
What type of visit?
Please complete items 1 and 2:
Behavioral Health
Rate your care experience with the following:
1. Was it easy to make an appointment?
2. Did you wait a long time before being seen by the doctor?
3. Was the staff friendly and helpful?
4. Did your doctor listen carefully to your problem?
5. Did your doctor provide you with good care?
6. Did you make another appointment at this time?
Are there any Comments you would like to make?
Thank you for taking part in this survey. Please remember all answers are confidential!
          Patient Survey

2670 South White Rd.
Suite 200
San Jose, CA 95148
P: (408)729-9700
F: (866) 931-7822
Administration Office
Goal of Foothill Community Health Center

Foothill Community Health Center sites are Federal Tort Claims Act (FTCA) deemed facilities. Foothill Community Health Center is a 501 (c)3 non-profit community-based Federally Qualified Health Center (FQHC) offering comprehensive medical, dental, mental health, and specialty healthcare services. Foothill Community Health Center is a Health Center Program grantee under 42 U.S.C. 254b, and deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
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