Quality Assurance (QA) Survey

Required fields marked with a *

Date of Visit*

Were in for*

If other, please specify*

How would you rate...

I understand the next step in my care as explained by my provider.*

My provider answered all of my questions during my appointment.*

The office staff shows compassion.*

My nurse was attentive to my needs and answered my questions while I was receiving my treatment.*

The providers and staff of Illinois CancerCare are helpful when I have a concern.*

I would recommend Illinois CancerCare.*

Areas for Improvement*

Physician's Name (Optional)

Name (Optional)

First Last

Email (Optional)

Name

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