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* 1. Demographics

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* 2. Region

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* 3. Location

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* 4. My overall experience was positive.

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

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

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

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* 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? 

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

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