Internal Medicine Specialists

First Name:
Last Name:
Home Phone:
Work Phone:
E-mail:
Attending Physician:

How would you rate the following services?
Scheduling Department: Excellent Good Satisfactory Poor	Front Office Staff: Excellent Good Satisfactory Poor	Nursing Staff: Excellent Good Satisfactory Poor
Attending Physician: Excellent Good Satisfactory Poor	Overall Service: Excellent Good Satisfactory Poor

Are there any areas in which you feel we need to improve? (if yes, please specify in comments) Yes No
Was there any individual you feel was most helpful to you? Yes No (individual's name)
General Comments

If you would like to contact our administrative staff to express your opinion of any other area not addressed above, please email: admin@imsmed.org

We thank you for taking the time to voice your opinion and hope that your experience was a pleasant one.