Name *

First Name

Last Name

How long have you been going to The Kidney Clinic, LLC? *

Less than 6 months

At least 6 months but less than 1 year

At least 1 year but less than 3 years

At least 3 years but less than 5 years

5 years or more

In the last 12 months, how many times did you visit The Kidney Clinic? *

1

2-3

4-5

6 or more times

In the last 12 months, when you made an appointment for a follow-up, how often did you get an appointment as soon as you needed? *

Never

Sometimes

Usually

Always

In the last 12 months, if you phoned The Kidney Clinic during regular office hours, how often did you get an answer to your medical question that same day? *

Never

Sometimes

Usually

Always

Not Applicable

How long has it been since your most recent visit with The Kidney Clinic? *

Less than 1 month

At least 1 month but less than 3 months

At least 3 months but less than 6 months

At least 6 months but less than 12 months

Wait time includes time spent in the waiting room and exam room. During your most recent visit, did you see your physician within 15 minutes of your appointment time? *

Yes

No

During your most recent visit, did your provider explain things in a way that was easy to understand? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, did you talk with your physician about any health questions or concerns? *

Yes

No

During your most recent visit, did your physician give you easy to understand information about these health questions or concerns? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, did you physician seem to know the important information about your medical history? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, did your physician spend enough time with you? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, did your physician order a blood test, x-ray, or other test for you? *

Yes

No

Did someone from The Kidney Clinic follow up to give you those results? *

Yes

No

Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate you physician? *

1

2

3

4

5

6

7

8

9

10

Would you recommend The Kidney Clinic to your family and/or friends? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, were nurses and receptionists at The Kidney Clinic as helpful as you thought they should be? *

Yes, definitely

Yes, somewhat

No

During your most recent visit, did nurses and receptionists at The Kidney Clinic treat you with courtesy and respect? *

Yes, definitely

Yes, somewhat

No