Name
Date of last appointment*
Please answer the following questions to rate your level of satisfaction with the services we provide.
Ease of reaching our office on the telephone*
1
2
3
4
The length of wait time to get into our office for appointment*
1
2
3
4
The convenience of our office location*
1
2
3
4
Length of time waiting at the office*
1
2
3
4
Friendliness of our business office and reception staff*
1
2
3
4
Friendliness of our therapy staff*
1
2
3
4
Time spent with the chiropractor*
1
2
3
4
Explanation of your condition and treatment*
1
2
3
4
The thoroughness and competence of the chiropractor*
1
2
3
4
The outcome of your medical care (how you were helped)*
1
2
3
4
The comfort and cleanliness of our office*
1
2
3
4
Our staff’s regard for your confidentiality and privacy*
1
2
3
4
If you have the opportunity, will you recommend our office to family and friends?*
Yes
Maybe
No
Additional Comments
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