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Patient Satisfaction Survey

Please fill out this form and let us know how we are doing!

Please tell us which healthcare professional you met with:
	* - These fields are required
Name:*
Date of Birth(mm/dd/yyyy):
Gender(M or F):
Home Phone:
Email:*
Address:
City:
State/Zip:
Type of Appointment:
Date of Appointment(mm/dd/yyyy):
Occupational Therapist Physical Therapist Physician
Please tell us how long you waited to see your healthcare professional:
I did not wait at all. I waited less than 15 minutes I waited between 15-30 minutes I waited more than 30 minutes
Did you feel that we answered all your questions?
Yes No
Did you find our office and exam rooms clean?
Yes No
Did you find our office staff helpful and polite?
Yes No
Did you find our office easy to find?
Yes No
Was parking a problem?
Yes No
Were you provided with information such as printed materials or website addresses to learn more about your healthcare issues?
Yes No
Would you tell a friend or family member to come to our practice if they had a problem like yours?
Yes No
Was the paperwork too much to fill out?
Yes No
Did you receive an appointment within 48 hours?
Yes No
Comments

The Spine Center