PatientConnections - Branded Experiences for Customers
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Practice Registration Form
Practice Registration Form - Draft example
PRACTICE REGISTRATION
1- How did you find this practice?
Words of mouth
Internet
Newspaper
Walked past it
Other (please specify)
2- What was the reason for leaving the previous practice?
Moving home
Required additional services
Didn't get along with the practice staff there
Too expensive
Other (please specify)
3- Why did you choose this practice?
Reputation
Location closest to home/work
Convenience
Services & treatments available
Languages spoken
Rates/Costs
Other (please specify)
4- What are the treatments and services you would be interested in?
Improving your smile
Teeth whitening
Invisible teeth alignment
Cosmetic adjustments
Other services (please specify)
5- From time to time, practices and Clinicians make discounts available for certain treatments. Would you be interested in finding out when these offers are available?
Yes
No
Ask me Later
6- What can we improve further / any other comments?