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

Dr. Amanda Barker Assell Dr. Sandi Farnham