Medical Clinic Interest Survey

The purpose of this survey is to gage the interest of the membership in utilizing a medical facility or clinic on campus, or in close proximity to the church.

If there was a medical facility on Mount Zion’s campus or in close proximity would you utilize it? *

Yes

No

Do you currently have a primary medical provider? *

Yes

No

On a scale from 1-5, with 5 being very difficult: How difficult is it to get in to see your medical provider? *

1

2

3

4

5

If there was a medical facility on Mount Zion’s campus or in close proximity, what services would you like to see offered? *

Would you consider changing your primary medical provider to utilize medical services if offered on Mount Zion’s campus or in close proximity? *

Yes

No

Do you currently have health insurance? *

Yes

No

If you don’t have health insurance, would receiving medical services on a sliding fee help you?

Yes

No

What city do you live in? *

What is your zip code? *

What is your age? *

Do you have any special needs? Please list below: *

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