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Client Experience Questionnaire

Requested Information
How did you choose our practice?
Your telephone experience: (check all that apply)





Your impression of our Receptionist (over the phone): (check all that apply)



Your impression of our Receptionist (in person): (check all that apply)






Your impression of our reception area: (check all that apply)




Your impression of our parking lot/grounds: (check all that apply)


Your impression of our website: (check all that apply)




Your impression of our Doctor: (check all that apply)







Will you recommend us to others?
Why or why not?
What suggestions do you have for improving the office, staff or procedures?

Additional Questions
Was your waiting time reasonable?
Do you feel the fees were reasonable?
Did you understand all our fees?
If you marked "No" please explain.

If you would like us to contact you, please fill out the necessary information.
Name:
Email:
Phone: