| |
| * Do you or anyone in your immediate family work in any of the following fields? |
| |
|
|
|
|
| |
| * Into which age range do you fall? |
| |
|
|
| |
| * Are there children/dependents in your household under the age of 18 for whom you are responsible for medical care? |
| |
|
|
| |
| * How many children/dependents in your household are under the age of 18? |
| |
|
|
|
|
| |
| * Are your children/dependents covered under your healthcare plan? |
| |
|
|
| |
* Do you currently have a primary care physician/doctor?
By primary care physician/doctor, we mean a physician who provides routine medical care with whom you have an ongoing relationship. |
| |
|
|
| |
| * From which sources did you learn about urgent care as an option for medical treatment? (Select all that apply.) |
| |
|
|
|
| |
| * Please list the name(s) of any urgent care centers that come to mind. | | |
|
|
| |
| * Have you ever heard of the following urgent care centers? (Select all that apply.) |
| |
|
|
|
| |
| * Please check all of the urgent care centers below that you recognize. |
| |
|
|
|
| |
| * Please select all of the urgent care centers that you have ever visited from the list below. (Select all that apply) |
| |
|
|
|
| |
| * Have you visited any of these urgent care centers in the past 12 months? (Select all that apply.) |
| |
|
|
|
| |
| * What led you to visit another urgent care center besides Urgent Care of Connecticut in the past year? (Select all that apply.) |
| |
|
|
|
| |
| * During your past visit(s) to an urgent care center, who received the medical care? (Select all that apply.) |
| |
|
|
|
| |
| * Have you visited a hospital emergency room in the past 12 months? |
| |
|
|
| |
| * What source(s) of information did you use to learn about Urgent Care of Connecticut before your visit? (Select all that apply.) |
| |
|
|
|
| Please rate your satisfaction with each attribute as it pertains to Urgent Care of Connecticut.
|
|
|
|
| How likely would you be to use each of the following services if they were available through Urgent Care of Connecticut?
|
|
|
|
| On a scale of 1-10, with 10 being the highest, how likely are you to recommend each of the following urgent care centers to a friend?
|
|
|
|
| |
| * What words come to mind that best describe your experience at Urgent Care of Connecticut? | | |
|
|
| |
| * What do you like most about Urgent Care of Connecticut? | | |
|
|
| |
| * What, if anything, would you like to see changed or improved at Urgent Care of Connecticut? | | |
|
|
| |
| * Into which ethnic group do you classify yourself? |
| |
|
|
| |
| * In what range does your household income fall? |
| |
|
|
| |
| * What is your highest level of education completed? |
| |
|
|
| |
| * Please enter your email address to be entered into the sweepstakes to win a new iPad and $100 iTunes gift card. The view the official sweepstakes rules, click here. | | |
|
|
Loading...
