Date of Visit


Patient Type


Scheduling-appointment convenience

Check in-friendly, helpful

Wait Time-comfortable and pleasant

Physician/provider-were you satisfied

Treatment/diagnosis/medications-clearly explained

Checking out –friendly, helpful

Prescriptions/lab results- timely-manner

Overall-cleanliness, efficiency

Billing-timely and accurate

Was our Medical Spa rewards program explained to you?

Who was your favorite employee today and why?

What could we do to improve our service to you?

Comments/Suggestions: Please note the name of the employee who recommended you fill out this form