AOC My Care Feedback Survey

Name of physician you saw during your most recent visit.*

Please select the location in which you receive care?*

How would you rate your overall experience on a scale from 1-5? (5 is best)*

Did we meet your expectations?*

Absolutely! You exceeded my expectations
Yes, you met my expectations
No, you did not meet my expectations

Did we listen to your needs and concerns?

Were your concerns addressed?*

Yes, everyone addressed my concerns
Yes, the doctor addressed my concerns
Yes, the staff addressed my concerns
No, the doctor did not address my concerns
No, the staff did not address my concerns
No, no one addressed my concerns

Did we explain our process well?*

Yes, everyone explained well
No, no one explained well
Yes, the doctor explained well
Yes, the staff explained well
No, the doctor did NOT explain well
No, the staff did NOT explain well
I did not need any explanations

If a friend, family member, or a colleague was looking for a new doctor, would you recommend us?*

Absolutely!
Probably
Maybe
No way!

Where have you learned about AOC online? (Select all that apply.)*

If you selected "other" above, please describe below.

Now is your chance! If there is anything else that you would like to share with us that we did great or that we need to improve, please complete the information below.

If you are comfortable providing your name, please complete the information below. If not, your information will be grouped and used for training purposes.

First Last

May we contact you to follow-up?

Yes
No

Email (not required)

Phone (not required)

Survey completed by patient or AOC staff member?

Patient
Staff

AOC My Care Feedback Survey

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