Survey

Satisfaction Survey

Fields marked with * are required.

Please select the purpose of this visit: *

Other Visit Purpose:

Please enter your First and Last Name. *

Please enter your date of birth. *

Do you know the name of the person that greeted you at the front desk? *

Yes

Not Applicable

If so, who?

Was our staff courteous and helpful? *

Yes

Not Applicable

Did the front office ask at least 2 questions to confirm your identity? *

Yes

Not Applicable

Was our facility clean and well-maintained? *

Yes

Not Applicable

Did our staff provide you with immediate attention? *

Yes

Not Applicable

If not, how long was the wait?

Did the medical Staff review any medications you have been taking? *

Yes

Not Applicable

Were all calls returned to you within 36 hours? *

Yes

Not Applicable

Did you receive a confirmation call at an appropriate time? *

Yes

Not Applicable

Was the seminar helpful in making your decision on whether the LAP BAND® may be right for you? *

Yes

Not Applicable

Were all your questions answered? *

Yes

Not Applicable

Would you recommend our service to your friends and family? *

Yes

Not Applicable

Do you have any additional comments or notes?