Feedback Form – Doctors House Call

Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Doctors House Call is easy to navigate and understand.	Doctors House Call is easy to navigate and understand. Strongly Disagree	Doctors House Call is easy to navigate and understand. Disagree	Doctors House Call is easy to navigate and understand. Neutral	Doctors House Call is easy to navigate and understand. Agree	Doctors House Call is easy to navigate and understand. Strongly Agree

Please type any additional feedback related to improving our website. *

Please rate the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Installing the App for Virtual Office Exam was easy.	Installing the App for Virtual Office Exam was easy. Strongly Disagree	Installing the App for Virtual Office Exam was easy. Disagree	Installing the App for Virtual Office Exam was easy. Neutral	Installing the App for Virtual Office Exam was easy. Agree	Installing the App for Virtual Office Exam was easy. Strongly Agree
The patient forms were easy to complete.	The patient forms were easy to complete. Strongly Disagree	The patient forms were easy to complete. Disagree	The patient forms were easy to complete. Neutral	The patient forms were easy to complete. Agree	The patient forms were easy to complete. Strongly Agree
The Office Manager was courteous and helpful.	The Office Manager was courteous and helpful. Strongly Disagree	The Office Manager was courteous and helpful. Disagree	The Office Manager was courteous and helpful. Neutral	The Office Manager was courteous and helpful. Agree	The Office Manager was courteous and helpful. Strongly Agree
My physician experience was positive and satisfactory.	My physician experience was positive and satisfactory. Strongly Disagree	My physician experience was positive and satisfactory. Disagree	My physician experience was positive and satisfactory. Neutral	My physician experience was positive and satisfactory. Agree	My physician experience was positive and satisfactory. Strongly Agree
My overall experience using Virtual Office Exam was positive.	My overall experience using Virtual Office Exam was positive. Strongly Disagree	My overall experience using Virtual Office Exam was positive. Disagree	My overall experience using Virtual Office Exam was positive. Neutral	My overall experience using Virtual Office Exam was positive. Agree	My overall experience using Virtual Office Exam was positive. Strongly Agree
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree

Please type any additional feedback concerning your visit and experience. *

Please rate the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Making an appointment was simple.	Making an appointment was simple. Strongly Disagree	Making an appointment was simple. Disagree	Making an appointment was simple. Neutral	Making an appointment was simple. Agree	Making an appointment was simple. Strongly Agree
It was easy to reach a staff person.	It was easy to reach a staff person. Strongly Disagree	It was easy to reach a staff person. Disagree	It was easy to reach a staff person. Neutral	It was easy to reach a staff person. Agree	It was easy to reach a staff person. Strongly Agree
This appointment was convenient to my life and schedule.	This appointment was convenient to my life and schedule. Strongly Disagree	This appointment was convenient to my life and schedule. Disagree	This appointment was convenient to my life and schedule. Neutral	This appointment was convenient to my life and schedule. Agree	This appointment was convenient to my life and schedule. Strongly Agree
Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit.	Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit. Strongly Disagree	Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit. Disagree	Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit. Neutral	Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit. Agree	Overall, I find this virtual appointment more satisfactory than a traditional doctors office visit. Strongly Agree