352-753-4366 | PATIENT PORTAL LOG-IN | REQUEST AN APPOINTMENT PATIENT INFORMATION CENTER FORMS REQUEST AN APPOINTMENT Name * First Name Last Name Phone (###) ### #### Email Address * Patient's name, if appointment is not for you: What is the best time of day to contact you? Morning Afternoon Evening No Preference PATIENT PORTAL LOG-IN OR REQUEST FOR ACCESS FMI is pleased to announce a new, secure access point for patient, the Patient Portal. This portal provides safe access to set up and account, schedule appointments, pay bills and more. Click on the button provided to get direct access to your portal, or fill out the simple form below to request access. LOG IN TO PATIENT PORTAL Name * First Name Last Name Email Address * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country REGISTRATION FORM Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Address * Phone (###) ### #### PATIENT SURVEY Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Address * Home Phone (###) ### #### Work Phone (###) ### #### Insurance Plan Who was your physician? :: select one :: John A. Cowin, MD Carl O. Ollivierre, MD Gavril Green-Goodman, ARNP Which location did you visit? :: select one :: Leesburg The Villages Did you find our office location convenient? Yes No How did you hear about us? :: select one :: Family/Friend Another doctor Attorney Emergency room Phone book Insurance company Billboard Radio Television Internet How would you rate our switchboard and telephone service? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did you find it easy to make an appointment? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Was our staff helpful? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did the doctor clearly explain the problem and the treatment he prescribed? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did you feel that the doctor was truly concerned for your well-being? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did your physician spend adequate time with you during your visit? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did you feel that your check out and bill payment was courteous and efficient? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Was the staff helpful in helping you with your insurance coverage? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Did our medical assistants make you comfortable? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Do you feel you received the highest quality of care from your phsyician? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent Please rate your overall experience and quality of care provided by FMI. 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent How was your wait time? 1 = Very poor 2 = Poor 3 = Average 4 = Very good 5 = Excellent How many miles did you travel to reach our office? Would you recommend FMI to your family and friends? Yes No If you answered no to the previous question, please explain: Do you have any comments or recommendations on how we might serve you better? Would you like to be added to our Mailing List? Yes No FACEBOOK © 2016 Florida Musculoskeletal Institute, LCO Group, Inc. All Rights Reserved Privacy & Security Policy The Villages 910 Old Camp Road Building 110 Suite 112 The Villages, Florida 32162 (352) 753-4366