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How’d we do?

Submitting totally honest feedback is one of the best ways that you can help us provide you with the quality of service you desire. Please help us help you by taking a few minutes to respond to the following questions about your recent appointment. Please be candid.

Practitioner*
Which practitioner performed the service that you are responding to?
- Dr. Pat
- Karen
Service*
Which service did Dr. Pat provide?
- New Patient Examination
- Reevaluation
- Report of Findings
- Consultation
- Chiropractic Adjustment
- Neuromodulation Technique
- Weight Management Checkin
Service*
Which service did Karen provide?
- Massage
- Lymphatic Drainage
- Raindrop Technique
Discuss Benefits?
Did your practitioner explain the potential benefits of your therapy in this or a previous session?
- Clearly and Comprehensively
- Somewhat
- No
- Not Sure
Discuss Expectations?
Did your practitioner explain what you might expect to experience following your session?
- Yes
- Somewhat
- No
- Not Sure
Best Feature
What did you like most about your session?
Biggest Frustration
What was your biggest frustration with the session?
Questions
Let us know any remaining questions you may have about your recent session or any other aspect of our work.
Suggestions
Do you have any suggestions for how we might improve this service?
Satisfaction*
How would you rate your overall satisfaction with your service session?
- Very Satisfied
- Somewhat Satisfied
- Neutral
- Somewhat Dissatisfied
- Very Dissatisfied
Repeat
How likely are you to purchase additional care in the future?
- Very Likely
- Somewhat Likely
- Neutral
- Somewhat Unlikely
- Very Unlikely
Reason
Please explain why you feel this way about purchasing future sessions.
Follow Up
Are you willing to discuss what it would take to improve your experience? Please be sure to document any frustration in the previous field.
- Yes, I'd like to be contacted by a staff person.
- Yes, I'd like to be contacted by the practitioner.
- Yes, I will contact you.
- No, there is no need for follow up.
Your Name
Your name may potentially help us understand and respond to your feedback but it's totally optional. Feel free to remain anonymous if it helps you feel more comfortable.
First Last
Your Name*
Your name will help us follow up with you.
First Last
Follow Up Contact Information*
How would you prefer we follow up with you?
- Telephone
- Email
Phone Number*
Please enter the best phone number to reach you at.
Best Days / Times*
Please provide ranges as well as multiple options for the best days and times to reach you.
Email Address*
Please enter the best email address to reach you at.
Next Step

Once you are satisfied with your answers, click the "submit" button below.
Phone
This field is for validation purposes and should be left unchanged.

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