Your Physician may use a 3rd party to collate and report data from your responses. Thank you for your participation.
We would like to know how you feel about the services we provide so we can make sure we are meeting your needs.

* Please mark how well you think we are doing in the following areas during your most recent visit: Choose only one response per statement & respond to every statement.

  Poor-1 Fair-2 Ok-3 Good-4 Great-5
A. The ease of obtaining an appointment
B. Overall length of time you spent waiting in the office
C. Doctor, physician assistant, or nurse practitioner takes enough time with you
D. Doctor, physician assistant, or nurse practitioner treated you with courtesy respect, sensitivity, and friendliness
E. Nurse or medical assistants are friendly and helpful to you
F. Office reception and other staff are friendly and helpful to you
G. Your overall satisfaction with the quality of your medical care
H. The doctor or staff asked if I was experiencing any pain
I. I am satisfied with the way my pain is currently being treated

* J. I am currently experiencing some pain

* Age:

* Gender

* Race

* Selects the location for this visit:

* Select the Healthcare Provider for this visit:

* Day of the week of your visit:

* Time of the day of your visit:

* Comments: