People Voice Survey

Name *

First Name

Last Name

Phone

(###)

###

####

Address *

We ask for your address so that we may better understand the healthcare services near where you live.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sometimes my doctor care more about what is convenient for him/her than about your medical needs. *

Select the button below that best describes your opinion of the statement above.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree