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Feedback

Here at Doctors At Your Home, Inc. we are always looking to improve the quality of our business. It is important to us that we deliver the best medical concierge services out there. By filling this short questionnaire it will help us to identify any area in need of improvement.

Patient Name *

Date Treated

The doctor arrived promptly:

Excellent

Good

Fair

Poor

The doctor clearly explained the diagnosis:

Excellent

Good

Fair

Poor

The doctor clearly explained available treatment options:

Excellent

Good

Fair

Poor

The Doctor thoroughly answered all of my question(s):

Excellent

Good

Fair

Poor

The Doctor was professional and respectful:

Excellent

Good

Fair

Poor

The fees were reasonable for the services provided:

Excellent

Good

Fair

Poor

Would you recommend us to your friends and family?

Yes

No

My overall experience with Doctors @ Your Home, Inc was:

Excellent

Good

Fair

Poor

How did you hear about Doctors @ Your Home, Inc?

How can Doctors @ Your Home, Inc. better serve you?

Additional Comments:

Authorization and Release Information:

With your permission, we would like to share your thoughts with potential clients. Your words will help them to understand how they can benefit from working with us, and why they should do so. Do I have your permission?

Yes

No