1. How did you first hear about us?

Please choose one: Advertisement Friend or Family Member Insurance Directory Physician Referral Website Posterboard (In front of center) Other

2. Rate your overall experience:

Please choose one: (Lowest to Highest) 1 2 3 4 5 6 7 8 9 10

3.Was the appointment scheduled at your convenience?

Yes No

4. Which location did you visit?

Please select a location: Altamonte Springs East Orlando Orlando Orange City Winter Park Celebration

5.How long did you wait before going to the exam/treatment room?

Please choose one: Less than 10 minutes Less than 20 minutes Less than 30 minutes Less than 1 hour More than 1 hour

6.Rate the customer service level of the office and Medical staff:

Please choose one: (Lowest to Highest) 1 2 3 4 5 6 7 8 9 10

7. I am a patient of:

Please select a doctor: Evans Amune M.D. Kayvan Ariani M.D. Diego Guerrero M.D. Brian Jager M.D. Michael Rubeis M.D. Suresh Kannan M.D.

8. How long was it before you were seen by the Physician after you were taken to the exam/treatment room?

Please choose one: Less than 10 minutes Less than 20 minutes Less than 30 minutes Less than 1 hour More than 1 hour

9.Rate your experience with the Physician:

Please choose one: (Lowest to Highest) 1 2 3 4 5 6 7 8 9 10

10. Were all of your questions answered by the Physician?

Yes No

Comments: