Action Chiropractic LLC Survey - New Patients
Please tell us how we are doing!
Which date did you receive care in the office? *
MM
/
DD
/
YYYY
Which services did you receive? *
Please check all the apply
Required
How would you rate your overall experience at Action Chiropractic? *
Poor
Excellent
Please answer the following questions about your visit: *
Very Poor
Poor
Fair
Good
Very Good
Wait time to see the doctor
Friendliness/courtesy of the doctor
Concern the doctor showed for your questions or worries
Information provided to you regarding your condition and treatment options
Degree to which the doctor explained your condition/treatment in words you could understand
Amount of time the doctor spent with you
Your confidence in the doctor
Please answer the following questions regarding the office and staff: *
Very Poor
Poor
Fair
Good
Very Good
The office was clean and inviting
Friendliness/courtesy of the staff
Staff was knowledgeable and helpful
Ease of scheduling/Availability of appointments
Staff explained insurance benefits and financial plans in a way you could understand
How likely would you be to recommend Action Chiropractic LLC to your family and friends? *
Not Likely
Very Likely
What can we do to improve our practice?
Your answer
Additional Comments/Concerns
Your answer
If you would like to receive automatic appointment reminders, please type your full name and the word "text", "email" or "call" in the box below
Example: John Smith, text
Your answer
Allow Action Chiropractic LLC to post your response to our website? *
With your permission, responses will be posted anonymously to our website.
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