Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

Z: Patient Satisfaction Survey - Care at Tricity Family Medicine

Please select Office location *

Holly Springs Office

West Cary Office

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.

Instructions: Please rate the service you received by checking the box that best describes your experience.

Ease of Getting Care

Easy to get appointment *

Never

Sometimes

Usually

Always

Can get same day appointments

Never

Sometimes

Usually

Always

Calls are returned within 24 hours *

Never

Sometimes

Usually

Always

Clinical Locations are easy to get to *

Never

Sometimes

Usually

Always

Waiting/Test Results

Wait less than 15 minutes in waiting room

Never

Sometimes

Usually

Always

Wait less than 15 minutes in exam room

Never

Sometimes

Usually

Always

Does someone follow-up with test results

Never

Sometimes

Usually

Always

Provider (Physician, Physician Assistant, Nurse Practioner)

Can choose the provider you see

Never

Sometimes

Usually

Always

Provider listens to your concerns

Never

Sometimes

Usually

Always

Provider takes enough time with you

Never

Sometimes

Usually

Always

Provider gives you good advice and treatment

Never

Sometimes

Usually

Always

Provider tells you ways to stay healthy and improve your own health

Never

Sometimes

Usually

Always

Provider provides referrals for specialists (surgeons, heart doctors, skin doctors, etc)

Never

Sometimes

Usually

Always

Provider provides referrals for support services

Never

Sometimes

Usually

Always

Provider asks if you got services at next appointment

Never

Sometimes

Usually

Always

Medical Assistants

Friendly and Helpful to you

Never

Sometimes

Usually

Always

Answers your questions

Never

Sometimes

Usually

Always

Medications

Provider explains why you are being prescribed a medication before it is given to you

Never

Sometimes

Usually

Always

Provider discusses your medications at every appointment

Never

Sometimes

Usually

Always

Payment

Explains what you pay

Never

Sometimes

Usually

Always

Facility

Neat and Clean building

Never

Sometimes

Usually

Always

Feel comfortable and safe while waiting

Never

Sometimes

Usually

Always

Confidentiality

Keeps my personal information private

Never

Sometimes

Usually

Always

Overall rating

Poor

Good

How many times have you been to the clinic?

1st time

2 to 5 times

6 times or more

Did you have an appointment today?

Yes

Do you consider this center your regular source of care?

Yes

Your Name: *

Date of Birth *

Preferred contact# *

Thank you for taking the time to give us feedback. Our team tries their best to deliver excellent patient care and your feedback help us to learn and do better. We really appreciate the time you took to help us improve our services. Thanks for being an awesome patient!

Notes/Comments

* Required field