Exit Survey
Patient Satisfaction
1. How Did We Do?
This is our Patient Satisfaction Form. Please answer all questions that apply. We hope to improve by learning from your feedback for the best experience here at AthletePlus.
    
1. Do you have less pain or able to function better after treatment at AthletePlus?
Yes
Not at all
Somewhat
    
2. What improvements can we make to ensure you and others have a positive experience at AthletePlus
    
3. How did you hear about AthletePlus Physical Therapy?
Friend
My Doctor
Searching on internet with Google/Yahoo etc
Facebook
Newspaper/magazine
Outdoor Signs
Coach/Trainer
Other
    
4. Rate your experience with the Front Office/Billing at AthletePlus Physical Therapy with 10 being "Outstanding" and 1 being "Poor"
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Choose from 1 - 10
    
5. Please rate your overall experience at AthletePlus with 10 being "Outstanding" and 1 being "Poor"
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Choose from 1 - 10
    
6. Know someone who we can help for neck/low back, knee, shoulder pain or another issue? Send them to AthletePlus and if they attend their evaluation, you will receive a FREE 30 minute massage here at AthletePlus.
Name:
Company:
Address:
    
7. Please indicate here to give permission for AthletePlus to use you or your son/daughter as a testimonial on our brochures, website, or TV commercials.
Yes
Yes, but do not use my full name
No thanks
Yes and I would be glad to make a video testimonial
    
8. Patient Name (Optional - can be anonymous if you like)
Name:

Done