EVALUATION FORM/COMPLIMENTARY LISTING


EVALUATION FORM/COMPLIMENTARY LISTING EVALUATION FORM (PLEASE TAKE A MINUTE TO TELL US HOW WE CAN IMPROVE THIS PUBLICATION.)


On a scale of 1 to 5 (5 being very useful) how useful did you find this publication?  1  2  3


 4  5


In what ways can we improve this publication? ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________


What did you like most?


____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________


Was there anything you expected to find in here, but did not? ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________


How often do you use it? More than once daily  Twice a month Daily


 Monthly Weekly  Less than 12 times a year


Where did you pick up this directory?  Library  City Hall


Are you a...  Physician


 Medical Staff Member


 Heritage Publishing, Inc.  Senior Centers


 Healthcare Facility  Physician’s Office  Other (Specify)______________________________


 Referral Nurse  Senior Citizen


 Physician Assistant  Nurse Practitioner  Case Manager/Social Worker  Newcomer  Government Official  Other______________________________________


Would you like us to contact you about advertising in the 2013-2014 The Greater Daytona Healthcare Guide?  Yes  No Contact Name:__________________________________ Phone Number: ________________________________


COMPLIMENTARY LISTING  New Listing  Revised Listing (Page number(s)______)


Name ____________________________________________________________________________ Specialty __________________________________________________________________________ Office Address ______________________________________________________________________ __________________________________________________________________________________ Office Phone ____________________________Office Fax __________________________________


The publisher’s policies on complimentary listings in the The Greater Daytona Healthcare Guide are as follows:


• Deadline for listings is April 26, 2013.


• One free listing under the classification of specialty per healthcare provider. • Listings under more than one classification are provided at an additional charge of $395.00.


MAIL OR FAX TO: HERITAGE PUBLISHING, INC. • 6620 Southpoint Dr. S., Ste. 310 • Jacksonville, FL 32216 Phone: 904-296-1304 • Fax: 904-296-8522 • www.heritagepublishinginc.com


184 2012-2013 The Greater Daytona Healthcare GuideTM  NPI Number _________________________


Heritage Publishing, Inc. © 2012


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