Patient Care Survey

We are committed to providing you a pleasant atmosphere and great service.
You can help us know how we are doing and how we can improve by filling
out this short survey.

All questions are required unless indicated as optional.

1. How would you rate the appearance of the clinic?
Excellent Very Good Neutral Not So Good Poor
2. Were you greeted when you entered the clinic?
Yes No Not Applicable
3. Did our staff help you with the paperwork?
Yes No Not Applicable
4. Did our staff answer all your questions?
Yes No Not Applicable
5. Did the therapist greet you and explain to you what they would be doing?
Yes No Not Applicable
6. Were you happy with the therapy received?
Yes No Not Applicable
Please provide additional comments here:
We occasionally update our testimonials page with new comments. May we use your comment?
Yes No Not Applicable
First Name:
Last Initial:
Email Address:
Street Address [optional]:
City [optional]:
State [optional}:	Alabama  Alaska  Arizona  Arkansas  California  Colorado  Connecticut  Delaware  District of Columbia  Florida  Georgia  Hawaii  Idaho  Illinois  Indiana  Iowa  Kansas  Kentucky  Louisiana  Maine  Maryland  Massachusetts  Michigan  Minnesota  Mississippi  Missouri  Montana  Nebraska  Nevada  New Hampshire  New Jersey  New Mexico  New York  North Carolina  North Dakota  Ohio  Oklahoma  Oregon  Pennsylvania  Puerto Rico  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Vermont  Virginia  Washington  West Virginia  Wisconsin  Wyoming
Zip [optional]:
Phone [optional]:
Please include me in your email list for occasional tips and news

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PLEASE NOTE that the information on this form will not be shared with or sold to anyone else.

THANK YOU for taking this survey!