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Patient Survey

We love to hear from our patients. Please let us know about your last visit to the clinic by filling out our online Patient Survey form. Thank you!

Full Name
E-Mail Address
Address
City
State
Zip
Home Phone
Work Phone
Date of Service (mm/dd/yyyy)

Appointment Scheduling

Courtesy of the schedules:
Poor    Fair    Average    Good    Excellent

Length of time until your appointment:
Poor    Fair    Average    Good    Excellent

Waiting Area

Cleanliness of the reception room:
Poor    Fair    Average    Good    Excellent

Length of your wait in the reception area:
Poor    Fair    Average    Good    Excellent

Clinical / X-ray / Casting Staff

Courtesy of the staff who takes you to the Exam Room:
Poor    Fair    Average    Good    Excellent

Courtesy of the Nursing Staff:
Poor    Fair    Average    Good    Excellent

Courtesy of the X-ray Staff:
Poor    Fair    Average    Good    Excellent

Courtesy of the Casting/Bracing Staff:
Poor    Fair    Average    Good    Excellent

Your Provider

Courtesy of your provider:
Poor    Fair    Average    Good    Excellent

Ability to have all of your questions answered by the provider:
Poor    Fair    Average    Good    Excellent

Treatment you received from your provider:
Poor    Fair    Average    Good    Excellent

Check Out

Courtesy of the check out staff:
Poor    Fair    Average    Good    Excellent

Easy of scheduling your next appointment and/or test:
Poor    Fair    Average    Good    Excellent

Overall satisfaction of your visit:
Poor    Fair    Average    Good    Excellent

If there is one thing you could change about your visit, what would it be?
Which provider did you see?
Who referred you to us?
Would you refer us to others?
Yes    No
Other Comments and Suggestions: