Impact PT Patient Satisfaction Survey

Please take a moment to help us make improve our service to you

Question	Excellent	Very Good	Fair	Poor	Very Poor
Overall impression of our clinic
Communication with our staff, both on telephone and in person
Waiting times for scheduling appointments and for being seen at the time of your appointment
Explanation of clinic paperwork and your Financial obligation for therapy services
Clinical staff’s courteousness, professionalism, and respect for your privacy/confidentiality
Therapist's willingness and ability to clearly answer your questions
Therapist's understanding of your condition
Your confidence in the therapist's ability to perform a thorough examination, accurately evaluate your condition, and provide appropriate treatment
Therapist's explanation of home exercise program and what you should expect after discharge from therapy
Please rate your willingness to recommend our clinic to your family and friends if they need physical therapy
Please share any comments or suggestions you have for our clinic:
Optional
Name: Email Address: Occupation: May We Use Your Name (Initials only) in testimonials? Yes     No