Client Questionnaire

Our goal is to provide you and your family with high quality, cost effective, walk-in medical care. We are always looking to better serve our patients and value each person's feedback. Please take a few moments to complete this questionnaire to allow us to better serve you.


Getting Acquainted

Date of Visit:    

Location:    Ashburn Leesburg Sterling Warrenton

Which Medical Provider did you see during your visit?    

Was this your first visit?      Yes    No

Where did you hear about Nova Medical Group?    Friend Family Employer Doctor Word of Mouth Community Event Movie Theater Newspaper Magazine Internet Search Facebook Phone Book Other

Was the facility clean and comfortable?      Yes    No

Was your check-in process pleasant and efficient?      Yes    No

Was your wait time acceptable?      Yes    No

Did the medical provider meet your expectations?      Yes    No

Were all of your questions answered?      Yes    No

Did you feel genuinely cared for?      Yes    No

Would you recommend the medical provider to your friends and family?      Yes    No

Was the nursing staff courteous and professional?      Yes    No

How satisfied were you with your overall experience at Nova Medical Group?
    Very Satisfied    Satisfied    Average    Unsatisfied    Very Unsatisfied

Would you return to Nova Medical Group?      Yes    No

What did you like most about your experience?


Do you have any suggestions or recommendations for improvement?


Additional Comments:


Full Name:    

Phone:    

Email: