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We are here to serve you!

Our goal is providing you with the best dermatologic care possible! Itís important to all of us that you are satisfied during your office visit and we would love to hear that we have met those expectations. Please take a moment to complete this survey and offer any suggestions or comments you may have to help us continue to meet those expectations or to improve our performance to better serve you as well as others in the future.

How would you rate the following: Very
Satisfied
Satisfied Neutral Dissatisfied Very Dissatisfied

HELPFULNESS OF FRONT OFFICE STAFF


HELPFULNESS OF NURSE/MEDICAL ASSISTANT STAFF


PHYSICIAN/PROVIDER CARE


OVERALL WAIT TIME (Check-In to Check-Out)


OVERALL EXPERIENCE


  Physician
Referral
Friend/
Family
Yellow
Pages
Internet Newspaper Magazine Other
(please specify)
How did you hear about us?
  Rome Cartersville Both

In which of our offices did your appointment(s) take place?

Suggestions/Comments:

                                   
Patient's Name (optional)

   

 

 
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Dr. Jason Smith  
103 John Maddox Drive - Rome, GA 30165  
Phone (706) 235-7711 - Toll Free:  (888)969-3376
Monday thru Friday 8am to 5pm
(closed 12noon till 1:30pm each day)