Patient:

E-mail Address:

How would you rate your overall visit?

Excellent      Very Good       Average      Not so good

When your appointment was over did you have a good understanding or your diagnosis and recommended treatment? (Check one)

Yes

I wish I knew more about my situation

Not really

Were your financial options explained to you? (Check one)

Yes

I already understand my financial options

No

Did you have to wait over 15 minutes past your appointment time to be seated? If so, how long?
(Check one)

No

30-45 min.

15-30 min.

over 45 min.

Did the staff greet you properly and make you feel comfortable? (Check one)

Yes

I don't recall

Not really

Would you refer your friends and family to us? (Check one)

Yes

I'm not sure

No

Please comment on how we could make your visit better or, new services you would like to see.