Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Select Location *Reliant Urgent Care - DTLAReliant Urgent Care - DTLAReliant Urgent Care - Huntington ParkReliant Urgent Care - LAXReliant Urgent Care - MontebelloReliant Urgent Care - Santa Fe SpringsOrganization *LAPDLAPDEmployee Serial Number *EMR Patient ID *Visit Type *Work Comp - New InjuryWork Comp - New InjuryWork Comp - Follow UpWork Comp - Physical TherapyWork Comp - OrthopedicEmployer ServicesWould You Like to Complete the Survey? *YesNoWas the facility clean and inviting? *YesNoNot ApplicableWas our staff professional and helpful? *YesNoNot ApplicableWere you treated by an M.D. and/or a P.A. at this facility? *Yes, an M.D.Yes, a P.A.Yes, both.Not ApplicableDid the provider listen to your problem? *YesNoNot ApplicableDid the provider involve you in the decision-making and options of your medical care? *YesNoNot ApplicableDo you agree with your treatment plan/work limitation as explained to you by the provider? *YesNoNot ApplicableDid the provider answer all your questions before you were discharged? *YesNoNot ApplicableHow would you rate your overall satisfaction with your medical care? *Very SatisfiedSatisfiedNeither Dissatisfied or SatisfiedDissatisfiedVery DissatisfiedDo you have any other feedback to share?Submit
