Patient Feedback Form Please provide your feedback to help us evaluate and improve the quality of our medical services. Date of Evaluation MM slash DD slash YYYY Name of Physician First Last Name of ClinicPlease provide any comments regarding Dr. Fletcher's performance or comments that would be helpful to potential clients considering seeking services from Dr. Fletcher. If you are comfortable adding your initials to these comments for use on Dr. Fletcher's website, please add them.Please select a performance rating for your doctor for each of the following questions:Did this doctor explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No Did this doctor listen carefully to you? Yes, definitely Yes, somewhat No Did you talk with this doctor about any health problems or concerns? Yes, definitely Yes, somewhat No Did this doctor give you easy to understand instructions about taking care of those health problems or concerns? Yes, definitely Yes, somewhat No Did this doctor seem to know the important information about your medical history? Yes, definitely Yes, somewhat No Did this doctor show respect for what you had to say? Yes, definitely Yes, somewhat No Did this doctor spend enough time with you? Yes, definitely Yes, somewhat No Your Initials(optional) Δ
