Question marked with * are mandatory.

DISCHARGE SURVEY

Q1. During Your Visits *
  Poor Fair Good Very Good Excellent
1. Courtesy of staff at the front desk
2. Length of wait before going to the treatment area
3. Comfort and pleasantness of treatment area
Q2. Appointment Setting *
  Poor Fair Good Very Good Excellent
1. Ease of scheduling your appointments
2. Courtesy of person who scheduled your appointment
Comments (describe good or bad experience)
Q3. Your Therapist *
  Strongly Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree
1. Can view things from my perspective (see things as I see them)
2. Understands my emotions, feelings and concerns
3. Was knowledgeable and clearly explained my condition/injury to me
4. Was skillful in treating me
Comment (describe good or bad experiences)
Q4. Your likelihood of recommending our clinic to your friends and relatives *
 
 
 
 
 
 
 
 
 
 
Q5. What is the most important improvement we can make?
Q6. Add any other comments below
Q7. Please provide your name and phone number
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