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