Patient Survey | Podiatrist, Foot Doctor Dallas, TX and North Dallas Neighborhoods

Please complete all required fields!

Ease of making appointment with our office? (copy) (*)

The time it takes someone to respond when you when you call our office (*)

If you have needed to contact your doctor during non-business hours are you satisfied with the response? (*)

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How well your doctor discussed proposed treatment options? (*)

Ease in obtaining follow-up information and care (test results, medicines, care instructions) (*)

How well did we teach you about improving your foot condition? (*)

Were you given educational materials related to your diagnosis? (*)

The way your doctor involves other doctors or caregivers in your care when needed? (*)

Our office’s convenience (location, parking, hours, office layout)? (*)

How caring would you say your doctor is? (*)

How caring would you say Our medical staff is? (*)

How caring would you say Our office staff? (*)

Your Age (*)

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Another comments (*)

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Disabled (*)

Yes No

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If Disabled, Mention the type of disability (*)

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Ethnicity: (as outlined by CMS) (*)

Asian/Pacific Islander/Native Hawaiian

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How long have you been a patient of this doctor? (*)

Less than 1 year 1-4 years 5-9 years 10 years and more

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How many times have you visited this doctor’s office in the past 12 months for medical care? (*)

Please sign with your initials (*)

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