Patient Satisfaction Questionnaire

Patient Satisfaction Questionnaire
Patient Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
How has your experience been while getting treated at BioCure?*

1

2

3

4

5

1 is Poor, 5 is Excellent
How is your treatment going?*

1

2

3

4

5

1 is Poor, 5 is Excellent
How do you feel about your overall health?*

1

2

3

4

5

1 is Poor, 5 is Excellent
Comments
What other services would you like to know more about?*

Complete Micronutrient ExamNAD+ Therapy - Brain OptimizationWeight Loss - SemaglutideWeight Loss - TirzepatideWeight Loss Peptide TherapyHuman Growth Peptide TherapyHair Regrowth Peptide TherapyTissue Healing Peptide TherapyGut Repair Peptide TherapyComprehensive Stool Exam (GUT HEALTH)Methylene Blue - Brain OptimizationTestosterone TherapyFemale Hormone OptimizationsNutritional SupplementsComplete Detox ProgramHeavy Metal DetoxGenetics ExamNone of the Above
Do you know anyone (FAMILY OR FRIEND) that could benefit from any of our services?

Receive $100 for every referral.* (See below for details)
Name:
Contact:
Name:
Contact:
Name:
Contact:
*You will have $ 100 credit applied to your account for every referral that commits to care. This credit can be applied to any future services.

Thank you so much for entrusting us with the loved ones you have referred above. We promise to live up to your expectations. In giving us their names and numbers, you are giving us permission to reach out to them on your behalf.
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