Office Survey

Dear Patient,

Please help us provide better service to our patients by sharing you opinions as to how we’re doing. You may sign the form or return it anonymously. Thank you.

Please rate the following on a scale of 1-10. With 10 being the best.

1 2 3 4 5 6 7 8 9 10 Ease of making appointment
1 2 3 4 5 6 7 8 9 10 Ease of finding the office
1 2 3 4 5 6 7 8 9 10 Convenience of office location
1 2 3 4 5 6 7 8 9 10 Attitude of Staff
1 2 3 4 5 6 7 8 9 10 Helpfulness of Staff
1 2 3 4 5 6 7 8 9 10 Pleasant waiting room
1 2 3 4 5 6 7 8 9 10 Punctuality of office visit
1 2 3 4 5 6 7 8 9 10 Appearance of staff
1 2 3 4 5 6 7 8 9 10 Appearance of doctor
1 2 3 4 5 6 7 8 9 10 Courtesy of Staff
1 2 3 4 5 6 7 8 9 10 Fair fees
1 2 3 4 5 6 7 8 9 10 Help with insurance
1 2 3 4 5 6 7 8 9 10 Adequate parking

Telephoning the office:
• Did you have trouble getting through? yes no
• Were you kept of hold for too long? yes no
• If the office was closed, were you satisfied with the information on the message? yes no

Comments:


Forms:
• Was the staff helpful in filling out paperwork? yes no
• Was the information asked of you clear? yes no
• Were you embarrassed by any of the questions? yes no
• Do you have any problems with our forms? yes no

Comments

Doctor’s Care:

• Did you see the doctor near your appointment time? yes no
• Were the doctor’s results explained clearly? yes no
• Did the doctor spend enough time with you? yes no
• Did the doctor explain the treatment required? yes no
• Did you have the opportunity to have your Questions and concerns answered? yes no

Comments:



Some of the reasons why I discontinued care include: (Check all that apply)
Could not afford treatments
Did not like the treatments
Did not like the doctor
I feel fine now
Inconvenient hours
Insurance won’t pay
Moved away from the office
No need to continue care
Adjustments were painful
Financials not explained well
Spouse urged me to stop
Did not get the results I wanted
Staff was not courteous
Too busy to get to office
Transportation problems
Treatments didn’t help
Other

If my problem was to return:
I would feel comfortable returning to the office for care
I would NOT feel comfortable returning to the office for care

Overall, I would rate the chiropractic care I received as:
Excellent Good Fair Poor Terrible


I came to the office for about visits/length of time.

Thank you for your time in evaluating our office.

OPTIONAL INFORMATION
 

I would like a response from your office.
I would NOT like a response from your office.

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