* 1. How easy or difficult was it to schedule your appointment at a time that was convenient for you?

* 2. Did your appointment with your provider start early, late or on time?

* 3. How much do you trust your provider to make medical decisions that are in your best interests?

* 4. How well did your provider answer your questions?

* 5. How well did your provider explain your treatment options?

* 6. How well did your provider explain your follow-up care?

* 7. Overall, how would you rate the service you received from the staff at our office?

* 8. How likely is it that you would recommend your provider to a friend or colleague?

* 9. Please enter any additional comments you would like to share...

* 10. Please enter your First Name and Last Initial

T