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Thanks for Your Referrals!

Receiving referrals from our current podiatric patients is the greatest compliment that we can receive. When patients trust us with the health and well-being of their friends and family members, we must acknowledge your vote of confidence. For each patient that you refer, we will send you lottery tickets as a small token of our appreciation to you following their visit with us. Be sure that your friend, family member or co-worker mentions your name as the reason why they are visiting us, and we will send you lottery tickets to scratch off. Thank you to all who have already referred us patients, and Good Luck!!!

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Beavercreek    Vandalia

North Main    Centerville

Springfield    Elizabeth Place

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Customer Satisfaction Survey

  • Welcome! Please fill the following form completely to be entered in to win our custom gift baseket.

  • Name *
    First
    Last
     
  • Date of Visit *
    MM
    /
    DD
    /
    YYYY
     
  • Location *
    Beavercreek
    Centerville
    Dayton (Main)
    Dayton (St.Elizabeth)
    Springfield
    Vandalia
  • Doctor *
    Dr. Adam Thomas
    Dr. Belinda Dotter
    Dr. Nicole Rahn
  • Please rate the following accordingly.
  • 1. The cleanliness and comfort of the office itself *
    Excellent
    Good
    Fair
    Poor
  • 2. The friendliness and courtesy of our staff *
    Excellent
    Good
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    Poor
  • 3. Discussion of diagnosis and treatment options so that you understood your choices *
    Excellent
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    Fair
    Poor
  • 4.The attitude and conversation between our physician and you *
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    Poor
  • 5.The overall satisfaction with your physician *
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    Good
    Fair
    Poor
  • 6. The waiting time in our reception area prior to being seen by the doctor *
    0-5 minutes
    6-10 minutes
    10-15 minutes
    16+ minutes
  • 7. The waiting time in the exam room prior to being seen by the doctor *
    0-5 minutes
    6-10 minutes
    10-15 minutes
    16+ minutes
  • 8. Your overall satisfaction with our practice. *
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    Good
    Fair
    Poor
  • You are our best judge. Please tell us how we can improve to better meet your needs. *
  • Additional Comments about practice or customer service *
    This space allows you to express yourself in any way that you like in regards to the Community Foot Specialists.