Patient Satisfaction Survey


Thank you for taking the time to complete this survey.

Quality care is our top priority, and the information you provide will be used to improve care for all future clients.  Please take a few moments to tell us about your experience at Lorenz Clinic.  Your answers are anonymous, so we hope you feel free to be honest with your thoughts and feelings.

We appreciate your feedback and time.

Step 1 of 4

  • Patient/Client

    Please answer the following questions as the patient.
  • Please indicate if you are the patient or the parent of patient from the dropdown below.
  • Please select your race/ethnicity from the dropdown.
  • Facility

  • Please select what clinic you go to from the dropdown below.
  • Front Desk

  • Provider #1

    After selecting your provider, please fill out the next section in accordance with how you felt your provider did for you or your child.
  • Please select the name of your provider from the dropdown below.