Satisfaction Survey Form - Evidence North

Name

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?

How likely are you to refer a friend or family to our (1 = Not at all, 10 = Extremely Likely)(Required)

Ease of booking and appointment availability(Required)

I am greeted in a positive manner(Required)

Clarity of billing and payment process(Required)

The online booking or payment system is easy to use(Required)

Yes	No	Didn’t use It

Additional comments regarding Front Desk experience

Which Practitioner(s) did you see?(Required)

My privacy and safety is respected(Required)

My clinician listens and understands my condition(Required)

I received clear instructions for home/work activities(Required)

My treatment plan included achievable recovery goals(Required)

I understand how to prevent re-injury(Required)

I understand if & when I should book future appointments(Required)

I am achieving the goals set at the beginning of care(Required)

Additional comments regarding your clinician experience

Cleanliness and maintenance of the clinic(Required)

Wait time before my appointment was reasonable(Required)

The cost of treatment was reasonable for the value I received(Required)

Q4.Additional comments regarding your clinic experiences (Optional)

Additional Feedback (Optional)

Full Name

Phone

Email