CLIENT EXPERIENCE FEEDBACK

If you are currently a chiropractic patient and would like to submit your own testimony, please feel free to complete the following Client Experience Questionnaire below, or you may download and print it out here to return to our office.

How did you choose our practice?
- A friend or relative recommended the practice
- I drove by and saw your sign
- I saw the practice in the Yellow Pages
- Found you through the Search Engines (Google, Yahoo, etc.)
How was your telephone experience?
Select all that apply.
- My call was answered promptly
- It was easy to make an appointment
- I was referred to the website to get necessary forms ahead of time
- I was placed on hold too long
- I was offered to be called back if needed
- I did not phone
What was your impression of our receptionist (over the phone)?
Select all that apply.
- Friendly and attentive
- Courteous
- Informative
What was your impression of our receptionist (in person)?
Select all that apply.
- Stood and greeted me
- Aware of purpose of visit
- Seemed warm and cheerful
- Gave me undivided attention
- Seemed hospitable
- Answered all my questions
What was your impression of our reception area?
Select all that apply.
- Comfortable
- Neat and clean
- Countertops free from clutter
- Retail displays well organized
- Child friendly
What was your impression of our parking lot/grounds?
Select all that apply.
- Clean
- I found a parking spot with ease
What was your impression of our doctors?
Select all that apply.
- Introduced himself/herself
- Listened to what I said
- Gave clear advice
- Answered all my questions
- Made me feel valued
- Seemed proficient and knowledgable
- Gave me the information I needed
Additional questions:
Select all that apply.
- Was your waiting time reasonable?
- Do you feel the fees were reasonable?
- Did you understand all of our fees?
Please explain your answers to "Additional Questions" for those that did not apply:
Would you recommend Impact Chiropractic to others?
- Yes
- No
Why or why not would you recommend Impact Chiropractic to others?
What suggestions do you have for improving the office, staff or procedures?
If you would like us to contact you, please fill out the necessary information.
Name
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Phone
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