Front Desk Forms

Adobe Acrobat Reader is required in order to print the provided forms; it is available as a free download. Please fill in all of the items as completely as possible by printing clearly in black or blue ink. Bring these completed forms with you and present them when you check-in for your appointment. Please have your most current insurance card and picture identification with you. If you have a copay then you will provide that at the time of your visit.


We appreciate your selection of the Baton Rouge Orthopaedic Clinic. Our physicians and staff strive to provide you with the best possible care. To help us evaluate our performance and become aware if the aspects of the practice that might be improved, please take a few minutes to answer our survey.

Date *
Please enter the month/day/year of your visit in the spaces provided
What was the purpose of your visit?
How did you find out about BROC?
1. If you spoke with someone by phone, they were helpful and courteous.
2. You were able to schedule an appointment when you wanted.
3. You were properly instructed regarding the information you would need prior to the appointment (i.e. insurance referrals, x-rays, etc.)
4. When you arrived at the clinic, the registration person was helpful and courteous.
5. You were satisfied with the registration process.
1. The waiting area was comfortable.
2. You found it easy to navigate your way around the clinic.
3. The waiting area was clean and attractive.
4. The exam rooms were clean and attractive.
5. The restrooms were clean and adequately supplied.
Nursing and Clinical Staff
Nursing and Clinical Staff
1. The clinical staff was friendly, courteous and helpful.
2. The clinical staff answered my questions completely and to my understanding and responded to concerns or complaints made during my visit.
3. The clinical staff was knowledgeable and skilled in the treatment they provided.
4. The clinical staff maintained my privacy.
5. The X-Ray staff answered my questions completely and to my understanding and responded to concerns or complaints made during my visit.
1. The physician was highly competent in technical skills and thoroughness.
2. The physician listened to my concerns and answered questions in terms that were understandable.
3. The physician was courteous, respectful, sensitive and friendly.
4. The physician spent sufficient time with you.
5. The physician/clinical staff appropriately explained any medical procedures and tests.
Please select your physician for this visit:
Overall Experience
Please select all that apply.
Please estimate your wait time once you checked in with the clinical staff (include time spent getting x-rays if applicable)