Post Visit Survey
In an effort to help serve you better in the future, please answer this short post visit survey:
How did you hear about the practice?
Doctor Referral
Patient Referral
Search Engine
Friend
Online, please specify which website below
You were seen by:
Dr. Charlot
Other
On a scale of 1-5, how would you rate your experience with the physician:
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
On a scale of 1-5, how would you rate your experience with our front staff?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Is there anything that you feel that our practice should be doing differently, or could improve on?
Is there anything that we are doing especially well?
Are there any staff members that you would like to mention in particular?
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