Patient Survey

1. What service(s) did you have completed during your most recent office visit? Check all that apply. A. Patient Exam B. Routine Check-up C. Lab Work D. Procedure E. Procedure Follow-up

2. Five being the best, how would you rate our facility? 1 2 3 4 5

3. Five being the best, how would you rate our staff? 1 2 3 4 5

4. Would you recommend our practice to family or friends? Yes No

5. Any additional feedback you would like to provide to our office in regard to your recent visit?