Fields marked (*) are compulsory

	First Name *
	Last Name *
	Date of Birth *
	E-Mail Address *
	Date of Service/Appointment *
	Was your initial phone call handled promptly and efficiently? *			Yes		No
			Comments
	Approximately how long did you wait before your call was handled?*			5 Min or Less
				10 Min or Less
				Greater than 10 Min
	Was your appointment scheduled to your satisfaction? *			Yes		No
			Comments
	Were you greeted in a friendly, professional manner when you arrived in the office?  *			Yes		No
			Comments
	How long after your scheduled appointment time, were you able to see the physician?*		(select your Period) Less than 15 minutes Less than 30 minutes Less than 45 minutes More than 45 minutes
	Did the clinical office staff (medical assistants, X-Ray Technologists) conduct themselves in a professional manner? *			Yes		No
			Comments
	Did your encounter with the physician meet your expectations? *			Yes		No
			Comments
	Was your check-out procedure handled in a professional, efficient manner?  *			Yes		No
			Comments
	If you had any interaction with the Collections, Bill Pay or Reimbursement Services Department was your experience to your satisfaction?  *			Yes		No
			Comments
	Enter the code as it is shown: *