1. Was this your first visit? ............................................. Yes No

2. Did you have a Scheduled appointment? ...................... Yes No

3. Will you return for additional care if needed? ................ Yes No

4. Would you recommend us to a friend? ......................... Yes No

1. Courtesy/friendliness shown to you by our staff over the phone:

Excellent Very Good Good Fair Poor

2. Ease of scheduling your appointment with our office:

Excellent Very Good Good Fair Poor

3. Waiting time:

Excellent Very Good Good Fair Poor

4. Overall staff rating:

Excellent Very Good Good Fair Poor

5. Overall Doctor rating:

Excellent Very Good Good Fair Poor

6. Overall experience rating:

Excellent Very Good Good Fair Poor