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DISCHARGE SURVEY

Q1. Which location did you visit? *
Q2. Which service did you attend? *
 
 
 
 
 
 
 
 
Q3. During Your Visits *
  Poor Fair Average Good Excellent
1. Courtesy of staff at the front desk
2. Length of wait before going to the treatment area
3. Comfort and pleasantness of treatment area
4. Cleanliness of the clinic
Q4. Your Therapist *
  Strongly Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree
5. Frequency of scheduled visits were appropriate
6.I completed my treatment and was discharged at a time I felt was appropriate
1. Understands my feelings and concerns
2. Was knowledgeable and clearly explained my condition/injury to me
3. Was skillful in treating me
4. Appointments were appropriate in length
7. I was satisfied with my treatment outcomes
Comment (describe good or bad experiences)
Q5. Scheduling/Insurance *
  Poor Fair Average Good Excellent
1. Ease of scheduling your appointments
2. Courtesy of person who scheduled your appointment
3. All your insurance/administrative questions were answered promptly
Comments (describe good or bad experience)
Q6. Your likelihood of recommending our clinic to your friends and relatives *
 
 
 
 
 
 
 
 
 
 
Q7. What is the most important improvement we can make?
Q8. Add any other comments below
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