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Please Complete the Following
Information for Us

It will help us understand what changes you would like to see on Dr. Myers' website in the future.  (We will not put you on any e-mail list and your information will be kept confidential: no one will know your identity.)  Thank you!   

How did you find our site:
Office staff told me the address
Promotional materials seen or obtained in the office
Heard the address while waiting on hold in the office
Texas Health Guide
Searched online
Referred by a friend or relative
Other:

General comments about our site:

Other feedback about our site or office:


What additional features would you like to see on our web site:


 Please take our communications questionnaire:
Would you like to communicate with the office through interactive forms on our web site to:
Schedule non-urgent appointments
Request a prescription refill
Fill out paperwork that is normally done in the office
Request a referral to another healthcare provider
Request a transfer of records
Request laboratory results

Would you like to communicate with our office via e-mail?   Yes No
Would e-mail make it easier to communicate with our office?   Yes No
Would you like to have health information sent to your e-mail box?   Yes No
Would you like to receive appointment reminders in your e-mail box?    Yes No
Would you like to receive routine well-care check-up reminders in your e-mail box?   Yes No

Please tell us some general information about yourself:

Age: Sex: City: State:

Occupation:

When you are ready, click "Submit" and you'll
return to the home page for Dr. Myers' website:

                       

Thank you for participating in our survey
and for visiting our web site.