Choctaw Nation Health Services Authoirty
Health Care Job Opportunities
Oklahoma Medical Job Provider


Name:
Email:
Date of Visit:
* 1. How would you rate the service you received?
 Excellent Good Fair Poor
2. Did you have an appointment scheduled or were you a walk in?
 Scheduled Walk-in
3. Were you seen in a timely manner?
(Such as within 20 minutes of your scheduled appointment) 		Yes: No: N/A
If not, how long did you wait? 20 to 60 Minuets 1 to 2 Hours
2 to 3 Hours 3 to 4 Hours Or More
Unspecified
4. Did your provider listen to your concerns and perform an examination?
(“Provider” can mean your doctor, physician's assistant or nurse). 		Yes: No: N/A
Provider's Name  
5. Did you understand the instructions given to you about your care? Yes: No: N/A
6. Were previous test results presented to you today? Yes: No: N/A
7. Were you treated with courtesy and respect? Yes: No: N/A
8. Did the staff wash their hands or use hand gel during your visit? Yes: No: N/A
9. What can we do to make your future visits better?
Do you have any other comments to tell us?
10. Did any one person stand out as being most helpful?
If so, what is their name
* 11. Which Facility did you visit?
12. Which department did you visit?


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Please feel free to contact the webmaster with any information, updates, or corrections.

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