APLMG Patient Experience Survey

General & Demographic Questions

First, we would like to get a general sense of who you are!

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Under 18

18-27

28-34

35-49

50-74

75+

Word of Mouth/ Personal recommendation

Web search (e.g. Google, Yahoo!, Bing, Yelp)

Social Media (e.g. Facebook, Pinterest, Instagram)

APLMG Special Event (e.g. Fall Supper Club, Free Class Day, Downtown Dance Party)

Other (please specify)