AVC Evaluation

Excellent Patient Care:

It’s our goal. . .

. . .and what you should expect.

You can help us meet our goal by filling out this brief survey. Thank you!

Today's Date*
MM slash DD slash YYYY
Date of Office Visit*
MM slash DD slash YYYY
Name*
First Last
Email*
I felt well treated by everyone at the Alaska Vein Clinic:*
- Yes
- No
I felt sufficiently educated / informed about my problems:*
- Yes
- No
I would recommend the Alaska Vein Clinic to others:
- Yes
- No
Comments:
I would like to be contacted regarding my comments on this form.
- Yes
- No

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