Patient Improvement Survey
SalesForce ID
Account Name
Why are you not getting the treatment with us?
Please Choose From the Following Options
Still undecided
Was told I’m not a candidate
Was too expensive
Researching more options
Can’t afford it
Can’t travel to Mexico
No treatment for my condition
Got treated in another clinic/hospital
Got treated locally in the United States
Found a better deal
Still have questions
Need more information to decide
I never intended to inquire
Was never contacted
Response time was too late
Other
Why Can't you Travel to Mexico?
No Visa
Too far away
Not safe
Bad health
Other
Please Explain Why
Submit
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