Foxworth Chiropractic
Please check the most appropriate response to the following questions:
Does the office staff call you by name? *
Do you feel that you’ve received the personal consideration you are entitled to? *
Are you made to feel welcome in our office? *
Please “Rate our office” in the following areas:
Office Atmosphere
Reading material *
Appearance of office *
Comfort of office *
Please “Rate our office” in the following areas:
Office Staff
Personal appearance *
Courtesy *
Telephone Manners *
Promptness *
Professionalism *
Explanation of Insurance & Financial Arrangements *
Please “rate our office” in the following areas:
Your Doctor’s
Personalized treatment/attention *
Explanation of your treatment *
Willingness to listen to you *
Personal habits and mannerisms *
Communication of your progress *
Professionalism *
Please write in your answers to the following questions:
What things about our office did you like the best? *
Your answer
What things did you like the least? *
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Would you recommend our office to your friends? Why or why not? *
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Have you recommended our office to your friends? If so, what was their response? *
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Is there any further information that you desire about our practice or Chiropractic care? *
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What other recommendations would you make to allow us to serve you better? *
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We would be grateful for you comments and suggestions. *
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May we share your survey with others? *
Name *
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Date *
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Thank you for participating in our efforts to bring quality Chiropractic Care to our patients!
Dr. Drew Cefalu | Dr. S. Neely Berry | Dr. Victoria Shearer | Dr. Gage Rodriguez
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