Thank you for seeing Dr. Marilyn Porter and entrusting our offices with your/your child's care. We would like to find out how we are doing and how we can do better. If you would take a few moments to provide us with feedback on our services, we would greatly appreciate it. (Feel free to fill out as many or as few of the below items as you have feedback on …) .

If any of your responses contain private medical information about you or your child - please do NOT submit this form online. Please print it out and mail or bring it into our offices where it can be reviewed directly by Dr. Porter).

	Name:
	Email:
1.	What has your overall impression of your visit(s) with Dr. Porter been to date?
2.	Do you have return visit(s) scheduled, or are you in the process of scheduling another visit, with Dr. Porter?
3.	If not, what are the primary reasons (treatment completed, seeking another doctor for insurance reasons, seeking another doctor for care reasons, location/distance, etc)
4.	What originally prompted you to see (or bring your child to see) Dr. Porter?
5.	What have been your impressions of/experiences with Dr. Porter's office and staff?
6.	Would you recommend Dr. Porter to a friend or family member experiencing similar issues? Why or why not?
7.	What changes do you feel would most improve/enhance your overall experience with Dr. Porter?
	Any additional Feedback/Comments, or your own personal Success Story:
	Please check to the left if you would be willing for us to utilize the feedback and comments provided here for promotional purposes, such as on our website.

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