Comment Card

Nothing is more important to us than your satisfaction. Please help us continue to grow and improve our services by commenting on your recent visit. All personally identifiable information will be kept strictly confidential.

Visit Information

Date of Visit *

Month

Day

Year

Which office did you visit? *

Which provider did you see? *

How long have you been coming to PHCA? *

Contact Information

Name *

Phone Number

Would you like someone to call you about your visit? *

Note: You must provide a complete phone number on this form if you wish to receive a call back. Thank you in advance.

Feedback

Please rate your visit overall *

What is your feedback regarding? *

Please tell us about your visit *

What specifically can we do to make your next visit better?

Did we do anything to enhance your visit? Please include staff names if available

Permission

Yes

Check this box if you would allow us to publish your comments.

Leave this field blank

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.

Search form

Comment Card