Contact Dr. Forsythe - Century Wellness Clinic

Dr. Forsythe's Century Wellness Clinic. would like to provide you with the best possible website information. Please take a minute to give us your feedback on what you would find helpful. Your responses are completely confidential.

1. Have you recently (6 months or less) consulted a cancer doctor? Yes No
2. Are you presently going through cancer treatment? Yes No
3. If Yes, what procedures have you or are you about to undergo? (Check all that apply) Surgery Chemotherapy Radiation
Other (please explain):
Alternative Treatments (please explain):
4. Were you, or are you, satisfied with the care received? Yes Somewhat No Not at All
5. Please list in order of importance (1=most important) the FIVE most important factors you consider when selecting a cancer doctor:
Reputation
Clinic Hours
Price or Cost of Procedures
Location of Office
Word-of-Mouth Comments
Office Staff
Convenience to Home
Doctor
Expertise
Advertisements
Board certification of Doctor
Other (please explain):
(please explain):
6. How did you find The Century Wellness Clinic and Dr. Forsythe website? Please specify sources:
7. Where did you hear about Dr. James Forsythe? Please specify sources:
8. What three websites do you visit at least once per week?
WebSite 1
WebSite 2
WebSite 3
9. How can we make this website more valuable to you?
Please tell us about yourself...
Gender Male Female
Name * First Last
Phone * - (###) - ### ####
Fax - (###) - ### ####
Email *
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Would you like to be added to our email list? Yes No

Contact Dr. Forsythe - Century Wellness Clinic

Contact Dr. Forsythe - Century Wellness Clinic

5. Please list in order of importance (1=most important) the FIVE most important factors you consider when selecting a cancer doctor:

8. What three websites do you visit at least once per week?

Please tell us about yourself...