INSTRUCTIONS: Please rate the following services while visiting AFC. Select the number that best represents your feelings. If a question does not pertain to you, select N/A. Thanks for your help!

4	Excellent
3	Good
2	Satisfactory
1	Poor
N/A	Not Applicable

Note: All fields are required unless marked with *.

1.	Patient's Name
2.	Patient's E-mail Address
3.	Patient's Gender Male Female
4.	Patient's Date of Birth
5.	Date of Visit
6.	AFC Location AlabasterBellwoodBessemerCorporate OfficeDaphneEastwood VillageFlintridgeForestdaleGardendaleGovernor’s HouseGreenspringsGreystoneHooverMadisonMontlimarNashville WestOrange BeachParkwayPelhamThe GroveThe GroveTrussvilleTuscaloosaUniversity DriveVestavia HillsWhitesburg
7.	Physician's Name
8.	Patients First Visit? Yes No
Staff Courtesy and Professionalism
9.	Clerical/ Front Office Staff 4   3   2   1   N/A
10.	Nurses, Lab Techs, and X-Ray Techs 4   3   2   1   N/A
11.	Care Provider 4   3   2   1   N/A
12.	Attention given to your healthcare needs by your Care Provider (Physician or Nurse Practitioner) 4   3   2   1   N/A
13.	How long was your office visit today? Less than an hour 1.5-2 hours 2.5-3 hours Greater than 3 hours
14.	What will be your overall assessment for today's visit? 4   3   2   1   N/A
15.	Cleanliness and appearance of the facility 4   3   2   1   N/A
16.	Would you recommend our clinic to others? Yes No
17.	How did you hear about AFC? TV Internet Word of Mouth Yellow Pages Location Other
18.	Did anyone inform you about U-Save Pharmacy (Birmingham and Huntsville only)? Yes No Does Not Apply
19.	Did anyone inform you about our other services WeighToLive NexStep Physical Therapy, and Specialty Services (Birmingham Area only)? Yes No Does Not Apply
20.	Please feel free to write any additional comments that you feel might help us improve our service.