Name
*
First Name
Last Name
Which State is the clinic you visited in?
*
Illinois
Indiana
Which Illinois Location did you visit?
Archer Heights
Aurora
Belmont Cragin
Blue Island
Bolingbrook
Bourbonnais
Burbank
Calumet Park
Carol Stream
Chicago Ridge
Cicero
Elmhurst on Butterfield
Elmhurst on York Street
Gage Park
Garfield Ridge
Hyde Park
Lakeview
Logan Square
Lombard
Matteson
Mayfair
Melrose Park
Mt. Greenwood
Norridge
Northbrook
Portage Park
Richton Park
River Forest
River North
Rogers Park
Roscoe Village
Skokie
Tinley Park on Harlem
Tinley Park on LaGrange
West Loop
Westmont
Wheaton
Wicker Park
Willowbrook
Which Indiana Location did you visit?
Cedar Lake
Crown Point
Crown Point (Beacon Hill)
Dyer
Griffith
Hammond
Hobart
Merrillville
Merrillville next to Walgreens
Michigan City
Munster
North Hammond
Portage
Schererville
When did you visit our clinic?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Were you pleased with your overall experience at our clinic?
Yes
No
Unsure
Was the Front Desk Staff polite and helpful?
Yes
No
Unsure
How long was your overall wait time?
Less than 15 minutes
15-30 minutes
30-45 minutes
45-60 minutes
Longer than 60 minutes
Were you satisfied with your overall wait time?
Yes
No
Unsure
Would you return for additional care if needed?
Yes
No
Unsure
Would you recommend us to your family and friends?
Yes
No
Unsure
Was your provider sensitive to your needs?
Yes
No
Unsure
Do you feel your provider listened to you?
Yes
No
Unsure
Who was your provider?
Suggestions on any services you would like us to offer.
Suggestions on how we can improve our services.
Any additional comments you would like to share with us.
If you would like to be entered in our drawing to win a $25 Amazon Gift Card, please enter your email address below.
example@example.com
If you would like to be contacted regarding your experience, please provide a good callback number.
Please provide the patient's full name.
What is the date of birth?
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