We Need Your Opinion Question Title * 1. Would you use house calls? If yes go to #2. If no go to #3. YES NO Question Title * 2. What time of day would be best for house calls? Please rank them. 1 2 3 4 5 Morning 9-12 1 2 3 4 5 Afternoon 1-5 1 2 3 4 5 Evening 6-8 1 2 3 4 5 Saturday morning 9-12 1 2 3 4 5 Saturday afternoon 1-5 Question Title * 3. Would you like the ability to check in electronically? YES NO Question Title * 4. Would you like the ability to pay in the exam room? YES NO Question Title * 5. Do you know about our Loyalty Program? Yes No Question Title * 6. Please put in your name and email address to be entered in the drawing. Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Done
