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Online Patient Survey
Patient Satisfaction Survey
Please rate the following, with 5 being best:
Poor
Satisfactory
Excellent
Ease of Scheduling and availability of appointments
1
2
3
4
5
Explanation of the vein procedure by Medical Staff
1
2
3
4
5
Discharge instructions given and adequate
1
2
3
4
5
Treated with courtesy and respect
1
2
3
4
5
Post treatment follow up
1
2
3
4
5
Staff competency/care
1
2
3
4
5
Overall cleanliness of facility
1
2
3
4
5
Overall experience
1
2
3
4
5
How did you hear about Advanced Vein Therapy?
Choose...
Radio
Print
TV
Direct Mail
Physicians Office
Friend/Family
Other
Did you come in for a consult but decide against treatment/chose another facility for treatment?
Choose...
Yes
No
Why?
Would you recommend Advanced Vein Therapy to others for Vein Procedures?
Choose...
Yes
No
Why or Why Not?
Would you be willing to share your experience as a testimonial for others?
Choose...
Yes
No
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