Skip to content

Patient Care Survey

Collier-Laurence is committed to a positive patient care experience.

Your feedback will help us improve our services and your time is greatly appreciated.

Please enable JavaScript in your browser to complete this form.

Get Started

Help Us Stay In Contact

Layout

First Name *

Last Name *

Email Address *

Which Location Did You Visit *

Phone Number *

Comments:

Step 2

Please tell us more.

Layout

How Helpful Was Our Staff *

5 Stars
4 Stars
3 Stars
2 Stars
1 Star

Scale: 5 = Outstanding, 1 = Needs Work

Which Provider Did You See? *

Step 3

How did you feel about your practitioner's evaluation process?

Layout

Please rate the attentiveness and proactiveness of your provider. *

5 Stars
4 Stars
3 Stars
2 Stars
1 Star

Scale: 5 = Outstanding, 1 = Needs Work

Comments

Step 4

Product Satisfaction

Layout

Please rate your satisfaction with the product you received. *

5 Stars
4 Stars
3 Stars
2 Stars
1 Star

Scale: 5 = Outstanding, 1 = Needs Work

Please explain how the device or product helped you: *

Almost Done!

Final Thoughts

If you were to list the reasons why you would refer us to a friend or family, what would they be?

Would you agree to allow us to share your story? *

Yes, I give permission to share my story
No, please do not share my info publicly.

Personal stories are displayed as testimonials on our website here: https://collieroandp.com/patient-care/patient-outcomes. Answers you provide could greatly help others. We are kindly asking your permission to use your feedback in our marketing. By clicking below you are consenting to share information submitted in this form. Your exact wording will be used along with your name. If you choose not to share, your data will only be used internally to improve our services.

Follow us on your favorite social channel!

facebook link
linkedin link
Instagram
pinterest link
twitter link
youtube link