2. Did you have an appointment? Yes No Please select an item.

3. How did you find us?

4. What is your home zip code?

5. How long did you have to wait before you were seen by a doctor?

6. How satisfied were you with the way you were treated by the staff in the office?

7. How satisfied were you with the way you were treated by the nurse?

8. How satisfied were you with the way you were treated by the doctor?

9. The amount of time the doctor spent with you?

10. The amount of time you had to wait before being seen by a doctor?

11. If you had to wait, were you advised of the wait time and given the option to see another provider or reschedule? Yes No NA Please select an item.

12. How satisfied were you with the way your questions were answered?

13. How would you rated the courtesy you were shown by the staff at our office?

Please tell us how much you agree or disagree with the following statements:

14. The front staff was knowledgeable.

15. The front staff was friendly and courteous.

16. The nurse was knowledgeable.

17. The nurse was friendly and courteous.

18. The doctor was knowledgeable.

19. The doctor was friendly and courteous.

20. My questions were answered fully.

21. I was given complete attention by the doctor.

22. My visit to the office was a pleasant experience.

23. Overall what was your overall impression of our office?

24. What, if anything, did you like most about your visit to our office?

25. What, if anything, did you like least about the office?

26. Please tell us what, if anything, we can do to make future visits to our office better for you.

27. OPTIONAL: You can leave your your name and/or contact information. If you wish to be contacted based on your specific feedback please indicate so. Otherwise your feedback will be completely anonymous.