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We are here to serve you!

Our goal is providing you with the best dermatologic care possible! It’s 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)