7740 Washington Village Drive

Suite 110

Dayton, Ohio 45459

Telephone: 937-439-4145

Toll Free: 877-298-0200

Fax: 937-439-4371

  
   

Patient Survey

  
 

We would like to know how you feel about the Dayton Bariatric Center. Your comments and suggestions are important and will help us improve our patient services. Please complete this confidential survey.

  
  Physician Name:                       
Patient Name: (optional)                             
Patient E-mail Address: (optional)           
   

 

    
Was this your first visit? Yes      No
Did you have an appointment? Yes     No
Will you return for additional care? Yes     No
Would you recommend us to a friend? Yes     No

 

   

How would you rate our staff?

    
  Office Receptionist / Telephone Personnel:    
Physician:
Waiting Time:
Overall Staff Rating:
How were you referred to the Dayton Bariatric Center?
If "Other" Please Explain:
Comments: