Menu

Patient Leave Form

To better serve our patients and community, we would be interested to know why you are choosing to leave our healthcare center.

Please check all that contribute to your decision to leave:(Required)

Moved from Area

Followed my Graduating Resident

Hours

Cost

Parking

Did not get care I wanted

Lack of Appointment Availability

Unable to see my Provider

Unwanted Provider Reassignment(s)

Wait Times During Appointments

Prescription Refill Process

Facility Accessibility

Facility Upkeep: cleanliness, etc.

Unhappy with experience with member of staff

If you selected 'Unhappy with experience with staff' please elaborate here.

Please rate the following. Feeling that we cared about you.(Required)

Please rate the following. Feeling that we listened to you.(Required)

Please share any recommendations you may have:

Name (optional)

Best Phone # to Contact (optional)

Can we contact you to talk further? (optional)

Yes

No