PATIENT'S SURVEY


Please take a moment to respond to these important questions. This information will be handled confidentially for your protection. If you have any concerns please review our Privacy Declaration.

What is your e-mail address? (Required)
 
 

Is this your first visit to MEDPRICE.COM or is this a return visit?
  1st visit
2nd visit
3 or more visits
 

What is your main reason for visitng or using MEDPRICE.COM?
  Personal needs
Spousal needs
Child needs
Friend's needs
Research
Other
 

What is your gender?
  Female
Male
 

What is your age?
  18-25
26-35
36-45
46-55
56-65
Over 65
 

In your opinion, is MEDPRICE.COM a user friendly site?
  Very friendly
Friendly
Not friendly
 

Do you find the MEDPRICE.COM process is helpful for your needs?
  Very helpful
Helpful
Not helpful
 

What is your highest level of education completed?
  Highschool
Highschool Equivalency
Associates Degree
College 4-year Degree
Trade school
Other School
 
   

What is your profession?
 

Additional_Comments:
 
 
Thank you for your time and consideration.
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