1. Date and Time of visit:
2. Name of the provider:
What type of visit?
Please complete items 1 and 2:
Dental
Behavioral Health
Optometry
Podiatry
CPSP/ObGyn
Chiropractic
Medical
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?
YES - NO
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
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affordable healthcare to our community"
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