Patient Survey Telemedicine version General Information Your Last Name * We only use your name to verify you were a patient. Date of Visit * Time of Visit * 891011121234 : 00153045 AMPM Healthcare Provider Seen on Day of Visit * Bennett, Brett A. Bennett, J. Gray Chustz, Philip L. Colley III, B. Judson Cotten, V. Reid Crowder, William H. Fletcher, Jefferson A. Gunyes, Richard D. Harkins, Douglas D. Hays, J. Clay Hutcheson, A. Gene Lott, Jimmy W. Ma, Jingyuan (Jimmy) McCearley, Sandra S. Mulholland, David H. Stokes, Donny R. Stone, R. Harper Young, D. Russell Barry, Amanda (Nurse Practitioner) Barry, Leslie (Nurse Practitioner) Byrd, Mindy Jo (Nurse Practitioner) Mitchell, Summer (Nurse Practitioner) Sterling, Angela (Nurse Practitioner) Vincent, Lynn (Nurse Practitioner) Ward, Beth (Nurse Practitioner) Whitley, Dean Elizabeth (Nurse Practitioner) Other Healthcare Provider Seen on Day of Visit Telemedicine Access Ease of accessing telemedicine appointment * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Strength of online connection to your physician * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Clarity of image on your screen * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Your Provider Friendliness/courtesy of your provider * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Explanations the provider gave you about your problem/condition * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Concern the provider showed for your questions or worries * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Providers efforts to include you in decisions about your treatment * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Instructions the provider gave you about follow-up care * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Your confidence in the provider * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Likelihood of your recommending this provider to others * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Your Appointment Ease of making appointment by phone * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Appointment available within a reasonable amount of time * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Waiting time in the virtual waiting room * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Your Overall Satisfaction With Our Practice * Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied N/A Comments Any additional comments? (Optional) I agree to the following * Yes All submissions are anonymous and no contact information is received by Jackson Heart when submitting this form. Therefore any questions/complaints submitted by this form cannot be responded to. Please contact us by phone or in person if you require a response from us concerning any matter.
