Visit Survey

* Please rate the following services by selcting the appropriate response:

	Excellent	Good	Average	Fair	Unsatisfactory
Cleanliness and overall comfort of office
Our team members' demeanor and professionalism
Timeliness of the visit
Ease of scheduling your appointment
The likelihood that you'll refer another patient to us

* How likely is it that you would recommend Dr. Park to another family member, friend, or colleague?

For your convenience, what days and times would you like to see incorporated into our schedule?

Any other comments, suggestions, or observations?

Could we use your comments in our marketing endeavors? Choose one of the options below if you approve. Thank you!

I prefer not to provide my name.

My full name approved for use.

My first name and first initial of last name only.

Name

Date

Thank you!

* Indicates Response Required