CCWC logo

Patient/Client Satisfaction Survey
Required Required Question(s)
Required 1.

Date(s) of visit:
 

  • 50 characters left.
2.


* Reason for visit:
 

  • 50 characters left.
3.


*Name of therapist(s):
 

  • 50 characters left.
4.

Referred by:
 

  • 50 characters left.
5.

On a scale of 1 to 4, with 1 being unsatisfactory and 4 being excellent, please rate the following:
 Unsatisfactory Neutral Satisfactory Excellent  
Ease in making an appointment  
Convenience of clinic location  
Convenience of parking  
Convenience of hours  
Comfort and attractiveness of waiting room  
Courtesy and knowledge of front-desk staff  
Promptness in being seen for appointment  
Professionalism of the therapist  
Knowledge and experience of therapist  
Thoroughness of initial evaluation  
  • Comment:

  • 500 characters left.
6.

On a scale of 1 to 4, with 1 being unsatisfactory and 4 being excellent, please rate the following:
 Unsatisfactory Neutral Satisfactory Excellent  
Attentiveness of therapist to your needs and goals  
Answers by therapist to your questions  
Home exercise program  
Modifications of home exercise program to your needs  
Explanation of insurance benefits  
Clarity of billing process  
Promptness of reply to voice messages or e-mails  
Website informative and easy to navigate  
  • Comment:

  • 500 characters left.
7.


*Would you recommend Cherry Creek Wellness Center to others?
Yes
No - please explain
Maybe - please explain
  • Comment:

  • 500 characters left.
8.

Additional comments?
 

  • 50 characters left.
9.

Please give us your name and e-mail address if you'd like to be entered into a drawing for a free 60-min. massage.
 

  • 50 characters left.