* 1. Demographics

* 4. My overall experience was positive.

* 5. I am satisfied with the outcome of my treatment.

* 6. I will recommend this practice to family and friends.

* 7. In your own words, tell us about your experience and results with our practice.

* 8. Do we have your permission to use your testimonial or images (anonymously) in our marketing materials, online or in print, or with other medical survey sites? 

* 9. Do we have permission to share your testimonial with any health care provider involved with your care?