Attention: Please do not fill this form out with your cell phone - you will be unable to submit it when complete. Please use a computer or a tablet :)
How have you felt (with your medication) since your last visit?
How satisfied are you with your day-to-day ability to accomplish tasks, communicate effectively, and pay attention?
1= POOR 10=GREAT
If yes, please describe.
Attention to patients that do NOT have Regence or Premera: If you pay out-of-pocket for visits, we offer 20% off when you pay on the same day as your appointment - let us know if you have any questions.
Thank you! Please press "submit" when you are finished.