WHAT TO EXPECT

NEEDED FORMS

BILLING AND INSURANCE

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PATIENT SURVEY

Patient Survey

Assist us in achieving our goal of 100% patient satisfaction.

We would appreciate it if you would take a few minutes to complete the following survey.
The information you provide will assist us in achieving our goal of 100% patient satisfaction.

Patient Name:
Location Treatment:
Therapist Name:

- - - - - Please rate the following based upon your experience - - - - -
Courtesy of Staff:
Front Office/Scheduling
Therapist Aide
Billing Staff
Communication regarding financial/Insurance information
Cleanliness of facility
Treatment plan and questions were answered by my therapist
Efficiency of treatment sessions
Sensitivity to my pain or discomfort
Overall care and service received
My home exercise program was clearly explained:
Therapy/exercise played an important role in my return to prior activity level.	Yes No
Were calls returned in a timely manner?	Yes No
Your waiting time was:
Would you refer a friend to this clinic?	Yes No
We welcome any additional comments you may have:
Please click the button right to send your feedback. We respect your privacy and do not share any information sent to us.