Physical Therapy One | Physiotherapy, chiropractic, massage therapy, acupuncture, orthotics - Patient Satisfaction Survey

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SURVEY

Patient Satisfaction Survey

Your feedback is very important to us. Please fill out this short survey and get a chance to win a complimentary massage session!

Please select the option that best reflects your opinion on each of the following questions:

* Required Feild

Patient’s Name:

Email: (Internal purposes use only)

Clinic Location you are attending: *

Please choose your reason(s) for seeking care: * Back Neck Shoulder Knee Hip Foot/Ankle Auto Accident Work Injury Orthotics Other

How would you rate the quality of care and services provided to you? * Excellent Good Fair Poor
How would you rate our staffs’ friendliness, knowledge and professionalism?* Excellent Good Fair Poor
Have the services you received helped you deal more effectively with your problems? * Yes, they helped a great deal. Yes, they helped somewhat. No, they really didn’t help. No, they seemed to make things worse
If you were to seek help again, would you come back to us? * Yes, definitely Yes, I think so I don’t think so No, definitely not
Would you feel good about referring someone who might need care for their pain or injuries? * Yes, definitely Yes, generally No, not really No, definitely not
In an overall, general sense, how satisfied are you with the service you have received? * Very satisfied Mostly Satisfied Indifferent Quite Dissatisfied
Additional Comments:

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