Patient Survey - Freedom Spine and Pain

Rate your confidence in the physician or physician assistant you interacted with:

Very confident

Confident

Somewhat confident

Not Confident

Rate how well the staff worked together to care for you:

(5 being the best staff experience)

How attentive was the physician or physician assistant toward your questions or worries?

During your most recent visit, did the physician or physician assistant listen carefully to you?

Yes

No

Rate how friendly the physician or the physician assistant was during your visit:

(5 being the most friendly)

What could we have done better?

Would you like to be contacted by our office to discuss your experience?

Yes

No

What number would you like to be contacted at:

May we leave a message at this number?

Yes

No

Name

Not required unless you wish to be contacted by our office to discuss your experience.

Age

Gender

How did you hear about us?

Select the type of visit you experienced (select all that apply):

New Patient

Follow-Up

Procedure

Surgery

How long have you been a patient?

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