Welcome to Century Wellness Clinic

1. Have you recently (6 months or less) consulted a doctor?	Yes No
2. Are you presently going through any medical treatments?	Yes No
3. If Yes, what procedures have you or are you about to undergo?
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 Cleanliness of Office Convenience to Home Doctor Insurance Plan Provider Expertise Advertisements Board certification of Doctor Discounts or Promotions Other (please explain):
6. How did you find The Century Wellness Clinic and Dr. Forsythe's 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?
9. How can we make this website more valuable to you?
Please tell us about yourself...
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Approximate Household Income:	Less than $25,000 $25,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 Over $100,000
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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.