Please tell us about the care you received today! InstagramThis field is for validation purposes and should be left unchanged.Today's date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your age:Gender identity:FemaleMaleOther not listed hereIf you're willing to speak with us about your experience, please provide your name and telephone number:Name First Last PhoneWho did you see today?(Required)Please select all that apply. I only visited the pharmacy today. I visited the pharmacy in addition to seeing a provider. Joyce Loos, NP Mattie Johnson, FNP Vickie Richards, FNP James Hartman, FNP Princika KC, PMHNP Karla Dieters, LCSW Krysten Keck, LCSW Marcia Weiland, DDS Heidi Hargraves Other: Nursing How well did your provider and clinical team listen to you?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team make enough time for you?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team explain what you want to know?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team give you good advice and treatment?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team address your reason for today's visit?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team answer your questions?(Required) Great Good OK Fair Poor N/A How well did your provider and clinical team discuss the next steps for your care with you?(Required) Great Good OK Fair Poor N/A Do you feel that what you pay for visits is affordable?(Required) Yes No Please rate your overall experience at the HealthWorks pharmacy:(Required) Great Good OK Fair Poor Please rate the service provided by staff at the HealthWorks pharmacy:(Required) Great Good OK Fair Poor Was the pharmacy waiting room clean and organized?(Required) Yes No N/A Do you feel the medications you fill at HealthWorks are affordable?(Required) Yes No N/A If you do not have insurance, did a pharmacy staff member describe the programs we can offer to lower prescription costs?(Required) Yes No N/A If you picked up a new medication today, did a pharmacist offer to counsel you?(Required) Yes No N/A Were your questions/concerns addressed if you had any?(Required) Yes No N/A If you waited in the pharmacy for your prescription to be filled, was the amount of time you waited acceptable to you?(Required) Yes No N/A How long did you wait for your prescription?Would you be interested in reviewing your medications with a pharmacist during a face-to-face appointment?(Required) Yes No Do you consider HealthWorks your regular place of care?(Required) Yes No Would you refer your friends or family to HealthWorks?(Required) Yes No Please let us know how we can improve our clinic services:Share your comments, recommendations, compliments or complaints; we're listening!
