Patient Survey

    Your Name (optional)

    Your Email (optional)

    *1. Age:

    *2. Gender:

    *3. What town are you from:

    *4. What was the purpose of the visit:

    *5. What Chiropractor did you see:

    *6. Ease of making an appointment:

    *7. Prompt return of calls:

    *8.Time in waiting room:

    *9. Time in treatment room:

    *10. Chiropractor took enough time with you:

    *11. Chiropractor explains your condition to you:

    *12. Chiropractor explains exercises and activities to help my condition:

    *13. All the staff was friendly to you:

    *14. Cost of services:

    *15. Explanation of the charges:

    *16. Was the clinic neat and clean:

    *17. Was the clinic easy to find:

    *18. Do you feel there was adequate privacy:

    *19. Would you refer friends or relatives:

    20. What did you like best about our clinic

    21. What did you like least about our clinic

    Additional Information