Patient Survey Form

Thank you for visiting Mid-America Orthopedics. We value feedback about your experience so we can provide you with the best service possible. Please complete and submit our Patient Satisfaction Survey below.

*=Required Field


* Office Visited:


* Provider:

How did you hear about MAO?

Is there a staff member who "knocked your socks off" with service today?

Please take a moment to "stay connected" by rating our service during your visit.

5 = Excellent. We truly provided 5-Star Service.
4 = Very Good. We met your expectations and went beyond.
3 = Good. We met your expectations.
2 = Fair. We came close, but did not meet your expectations.
1 = Poor. We did not meet your minimum expectations.

* 1. I will likely recommend MAO to a friend/neighbor.

* 2. My overall experience was...

* 3. I was able to schedule my appointment within a reasonable time frame.

* 4. The phone staff was professional and friendly.

* 5. The check-in staff was efficient and friendly.

* 6. The nursing staff was knowledegable, professional, and friendly.

* 7. MRI or DME staff was knowledgeable, professional, and friendly.

* 8. The billing staff was knowledgeable, professional, and friendly.

* 9. I recieved care, concern, and respect from my provider

* 10. Receiving a reminder call or email was helpful.

* What did we do well today?

* What can we do better inthe future?

* Name


* Phone

* Email