March Patient Survey
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1. Default Section

	Age	Gender
Please choose one response for each.	Background Information Please choose one response for each. Age	Gender

Have you visited our website, www.impactorthopaedics.com? Yes

	Exceeded Expectation	Met Expectation	Did NOT meet expectation	Disappointed	N/A
Front Desk (check in-out) Personnel	*Friendliness and courtesy shown by our staff. Front Desk (check in-out) Personnel Exceeded Expectation	Front Desk (check in-out) Personnel Met Expectation	Front Desk (check in-out) Personnel Did NOT meet expectation	Front Desk (check in-out) Personnel Disappointed	Front Desk (check in-out) Personnel N/A
Medical Assistant	Medical Assistant Exceeded Expectation	Medical Assistant Met Expectation	Medical Assistant Did NOT meet expectation	Medical Assistant Disappointed	Medical Assistant N/A
X-ray Technologist	X-ray Technologist Exceeded Expectation	X-ray Technologist Met Expectation	X-ray Technologist Did NOT meet expectation	X-ray Technologist Disappointed	X-ray Technologist N/A
Physician/PA	Physician/PA Exceeded Expectation	Physician/PA Met Expectation	Physician/PA Did NOT meet expectation	Physician/PA Disappointed	Physician/PA N/A

Comments:

Thoroughness of the examination and treatment. Exceeded Expectations

Met Expectations

Did NOT Meet Expectations

Disappointed

Comments:

Explanation of your condition and treatment options. Exceeded Expectations

Met Expectations

Did NOT Meet Expectations

Disappointed

Comments:

The comfort, appearance, and cleanliness of our facility. Exceeded Expectations

Met Expectations

Did NOT Meet Expectations

Disappointed

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