Midway Medical Center - Clyde, Canton, NC

Dear Patient,

Please take a few minutes of your time to help us. Our goal is comfort, convenience, and satisfaction as well as quality medical care for all our patients. Please tell us about our medical services, including staff and physicians. Please complete this survey and return it to the box in the lobby or you may mail it back to us at your convenience. Give us your opinion freely. You may use the blank lines below and continue on the backside if needed.

Your Doctor's Name	Date

A. YOUR ARRIVAL	Strongly Agree	Agree	Uncertain or Unsure	Disagree	Strongly Disagree	Does Not Apply
Was it easy for you to make an appointment?
Was the check-in process fast and efficient?
Was the waiting time in the reception area reasonable?
Did you see your doctor within 15 minutes of your appointment?
If your appointment time was delayed, were you informed?
When calling the office, were you able to reach staff in a reasonable amount of time?
B. OUR STAFF	Strongly Agree	Agree	Uncertain or Unsure	Disagree	Strongly Disagree	Does Not Apply
Was check-in and check-out staff friendly and courteous?
Were the nurses/medical assistants caring and concerned?
Were your past test results reported in a reasonable amount of time?
C. YOUR VISIT WITH THE DOCTOR	Strongly Agree	Agree	Uncertain or Unsure	Disagree	Strongly Disagree	Does Not Apply
Did the doctor listen carefully to you?
Did the doctor take time to answer your questions?
Did the doctor spend enough time with you overall?
Did the doctor treat you with courtesy and respect?
Were you satisfied with the way your doctor is treating your condition?
D. OUR FACILITY	Strongly Agree	Agree	Uncertain or Unsure	Disagree	Strongly Disagree	Does Not Apply
Overall comfort
Hours of operation
Parking
E. OVERALL SATISFACTION	Strongly Agree	Agree	Uncertain or Unsure	Disagree	Strongly Disagree	Does Not Apply
Our practice
The quality of your medical care
Using any number from 0 to 10 where 0 is the worst doctor possible and 10 is the best doctor possible, what number would you use to rate this doctor?
Would you recommend the doctor(s) to others? Please answer "Yes" or "No".
F. INFORMATION ABOUT YOU
Your Gender	Male			Female
Your Age	Under 18	19 - 30	31 - 40	41-50	51 - 60	Over 60

Please tell us about anything that was done well or anything that could have improved the care you received at your most recent visit. Use the space below.

Your name (optional):

Thank you for your valuable assistance in completing this survey. Your comments will enable Midway to continually improve our services and the quality of care for the benefit of all our patients.