Clinic Feedback Form

Please correct the errors described below.

Feedback

Brian F. Sweeney, Jr., MD

(907)562-2928

This form is designed to help us improve our service. We have changed a lot of clinic policies and procedures recently in an effort to provide better service. We understand there are always ways to improve experiences. We appreciate any input provided and are committed to improve patient experience.

Please rate the usefulness of our website (1- not useful 5-very useful)

1 2 3 4 5

Were we timely with your concerns?

Yes No

Were Procedure Preparation Instructions Clear?

Yes No N/A

Was our electronic signature process easy to use?

Yes No

Were there any issues with billing?

Yes No

Were there any issues with scheduling?

Yes No

Did our telemedicine link work well?

Yes No N/A

Which facility did you have your procedure at?

Alaska Digestive Center Providence Alaska Medical Center Alaska Regional Hospital Surgery Center of Anchorage

Please rate the procedure facility. (1-worst, 5-best). We can provide feedback to the facility.

1 2 3 4 5

Please Rate your overall experience with the office. (1-worst, 5-best)

1 2 3 4 5

Would you recommend us to your friends and family?

Yes No

Please leave recommendations for improvement.

Please tell us if there is something we did exceptionally well.

The rest is optional information.

Age

18-30 31-40 41-50 51-60 Over 60

Gender

Male Female Other

Name

Email address

Phone Number

We sincerely appreciate your input.

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Feedback

Brian F. Sweeney, Jr., MD

(907)562-2928

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