Services at Midland
We want to know more about your experiences at our offices. Please complete the following form. If you have questions or further comments please
email
or
contact us by telephone
.
Please complete:
Name:
Email*:
Telephone*:
Date of service:
Month
January
February
March
April
May
June
July
August
September
October
November
December
2002
2003
Location of your visit:
Select one
Wabash Avenue
Hometown - IL
Beverly
LaGrange - IL
Type of service you received:
Select one
Office visit
Treatment of fracture
Treatment of injuries
Podiatry
X-ray
Physical therapy
Hand therapy
Emergency care
Length of wait
Select one
Very short
Short
Average
Long
Courtesy of staff:
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Very good
Good
Fair
Poor
Overall satisfaction:
Select one
Very satisfied
Satisfied
Not satisfied
Likely to recommend Midland Orthopedic to others:
Select one
Very likely
Somewhat likely
Not likely
* Optional information
© 1999-2002 Midland Orthopedic Associates
312.842.4600