Satisfaction Survey Form

Book Appointment

This field is for validation purposes and should be left unchanged.

Q1. How likely are you to refer a friend or family to our clinic? (1=not at all, 10=Extremely Likely) *

Q1. How likely are you to refer a friend or family to our clinic? (1=not at all, 10=Extremely Likely) *(Required)

Q2. Please rate your front desk experience? *

Bookings are easy and times are convenient(Required)
I am greeted in a positive manner(Required)
Billing and payments are clear and accurate.(Required)

Q3. What is the name of the practitioner(s) you saw? *

Q4. Please rate your experience with your Therapist/Doctor *

My privacy and safety is respected(Required)
Listens to me and understands my condition(Required)
Explains what i can/can't do at home and work(Required)
We set attainable goals for my recovery(Required)
I know how to prevent this injury and/or when to re-book(Required)
I am achieving the goals set at the begining of care(Required)

Q5. Please rate your experience as it pertains to our clinic *

The clinic is clean and well maintained(Required)
The length of time I wait to be seen is reasonable(Required)
Treatment is affordable and provides good value(Required)

Q6. We appreciate your feedback. Is there anything we should know or that you can suggest so that we can continue to improve? (Optional)

Q7. Would you like us to contact you to further discuss your experience at our clinic? If so, please complete the form below. (Optional)