When was your most recent visit with this clinic or provider?
- Within the last 7 days
- 1-4 weeks ago
- 1-3 months ago
- More than 3 months ago
- Not sure
What type of visit was it?
- In-person visit
- Video/telehealth
- Phone consult
- Messaging/portal only
Which best describes the service you used?
How easy was it to schedule the appointment?
About how many minutes did you wait past your scheduled time? If none or not applicable, enter 0.
How did you schedule or request this visit? Select all that apply.
- Phone call
- Online patient portal
- Clinic website
- Walk-in
- Referral from another provider
- Mobile app
- Other
If scheduling was difficult, what made it hard?
Max 600 chars
Thinking about the clinician you saw, how would you rate each?
Overall, how would you rate the care you received?
Which technologies were part of this visit? Select all that apply.
- None
- Telehealth video
- Patient portal/app (forms, messages)
- Remote monitoring device
- Kiosk or check-in tablet
- Automated phone/SMS reminders
- Other
Please rate the reliability or quality of any technology used. If not used, select Not applicable.
Briefly describe any technical issues you experienced (if any).
Max 600 chars
How likely are you to recommend this clinic/provider to a friend or family member?
Attention check: To confirm you’re paying attention, please select “Agree.”
- Strongly disagree
- Disagree
- Agree
- Strongly agree
- Prefer not to answer
What is your age?
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Which gender do you identify with?
- Woman
- Man
- Non-binary
- Prefer not to say
What is the highest level of education you have completed?
- Less than high school
- High school or equivalent
- Some college or technical training
- Bachelor’s degree
- Graduate or professional degree
- Prefer not to say
What is your current employment status?
- Full-time
- Part-time
- Self-employed
- Unemployed and seeking work
- Not working by choice (e.g., student, caregiver, retired)
- Unable to work
- Prefer not to say
About how many healthcare visits have you had in the past 12 months?
Welcome! This brief survey takes about 5 minutes. Your responses are confidential and used for quality improvement.
Anything else you’d like to share about access, bedside manner, or technology during this visit?
Max 600 chars
AI Interview: 2 Follow-up Questions on your visit
Thank you for your time—your feedback helps improve care and access.