Patient Survey

We CARE about your satisfaction! Please take a moment to provide our office with your valuable feedback.

How would you rate us on the following?

*(denotes required field)

Care provided by the physician or clinician:

5 - I was highly satisfied
4 - I was satisfied
3 - I had no strong feelings either way
2 - I was somewhat dissatisfied
1 - I was highly dissatisfied

If you answered 1 or 2, please let us know what we can do to improve:

Overall atmosphere, cleanliness, and quality of the facility:

5 - I was highly satisfied
4 - I was satisfied
3 - I had no strong feelings either way
2 - I was somewhat dissatisfied
1 - I was highly dissatisfied

If you answered 1 or 2, please let us know what we can do to improve:

Courtesy of our staff:

5 - I was highly satisfied
4 - I was satisfied
3 - I had no strong feelings either way
2 - I was somewhat dissatisfied
1 - I was highly dissatisfied

If you answered 1 or 2, please let us know what we can do to improve:

Your visit overall:

5 - I was highly satisfied
4 - I was satisfied
3 - I had no strong feelings either way
2 - I was somewhat dissatisfied
1 - I was highly dissatisfied

If you answered 1 or 2, please let us know what we can do to improve:

Date of your visit:

Provider that I saw:

Dr. Tasto
Dr. Jain
Dr. Myer
Dr. Leek
Physician Assistant
Physical Therapist

Additional Comments:

Would you like to be contacted to discuss your feedback?

Yes
No

If so you answered "yes" above, please provide contact information below.

Name

Phone

Email address

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