Contact Information for a $50 gift card drawing! (Optional) $50 gift card choices: Target, Best Buy, Bed Bath & Beyond, or physical therapy.

If you received a survey in the mail please enter the form number in the bottom right hand corner (on the front of the survey) (Optional)

Please list the city of the clinic where you were treated. Required Question

Please list the name of the therapist who treated you. Required Question

1. Please rate the greeting you received each time you arrived at our clinic.

2. Rate the initial explanation of insurance, benefits, and billing by the front office staff.

3. Please rate the cleanliness of the facility.

4. Rate the friendliness, hospitality, and comfort with your care providers.

5. Rate the knowledge, understanding, education, and instruction given by your care provider.

6. Rate the satisfaction with your clinical care and outcome of that care.

7. Please rate your experience with our billing process.

8. Please rate any interaction you have had with our billing staff.

9. How did you hear about us?

10. Were you thanked for allowing us to care for you at the end of each visit?

Yes	No

11. If you are no longer visiting our clinic, has there been any follow-up communication with your therapist?

Yes	No	N/A

12. Would you refer a friend or family member to our clinic?

Yes	No	N/A

13. Approximately when did you begin care at our clinic?

14. Approximately how many visits have you had?

15. Are you currently being treated in our clinic?

Yes	No

15a. If not, how long ago was your last visit? (approximate month and year, i.e. 10/09)

16. Which new service would you like us to add?

	A "Patient Advocate" who estimates your out-of-pocket expenses and interprets insurance and billing
	Insurance authorizations and eligibility verified at a centralized location - business office.
	Scheduling handled through a centralized location - business office.
	Option to pre-authorize recurring credit card payments.
	Other (write in comments section below):

Comments / Suggestions?

Poor	Below Average	Average	Above Average	Outstanding

Poor	Below Average	Average	Above Average	Outstanding	N/A

Poor	Below Average	Average	Above Average	Outstanding

Poor	Below Average	Average	Above Average	Outstanding

Poor	Below Average	Average	Above Average	Outstanding