Customer Service Survey

Patient Name
Optional - you may remain anonymous
First Last
Therapist Name:
First Last
Score from 5: highly satisfied to 1: not satisfied
Please feel free to leave any additional comment that may be useful to our office. We want to provide the highest level of care possible!
Was it easy to schedule an appointment?
Comment
Did our supporting staff correspond with you in a prompt and friendly manner?
Comment
Was your doctor sensitive to your needs?
Comment
Was your therapy time spent efficiently?
Comment
Did we start on time?
Comment
Were the activities in-office explained thoroughly?
Comment
Were the home exercises and plan clearly explained?
Comment
Were you satisfied with the therapy?
Comment
How would you rate your overall experience?
Comment
Would you return to our office?
Comment
Would you refer a friend?
Comment
Please Describe Your Overall Experience
Thank you for your time!
Dr. Amanda Barker Assell Dr. Sandi Farnham

Score from 5: highly satisfied to 1: not satisfied