TOTAL PHYSICALTHERAPY - PATIENT SATISFACTION SURVEY

TOTAL PHYSICALTHERAPY - PATIENT SATISFACTION SURVEY

Thank you for choosing Total Physical Therapy as your physical therapy provider. We truly value you as a patient and would like to continue to provide outstanding service to your EVERY VISIT! Your honest feedback is appreciated. Please help us to exceed your expectations by filling out this brief survey. Thank you for your time.
Name of your Referring Physician:

Paperwork and procedures were explained in a clear and helpful manner.

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Handling of billing and co-pays

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Courtesy of office personnel

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Courtesy of clinic staff

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Phone etiquette of clinic staff

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Clinician introduced him/herself to me personally

Yes No

The evaluation and treatment I received was explained in a clear and helpful manner

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

The aides/techs were helpful and courteous in all aspects of my care

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Helpful responses were provided for my questions and concerns

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

My initial evaluation was scheduled within 24-48 hours or within my desired time frame

Yes No

Appointments were scheduled to my convenience

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

When I arrived for my appointment the service began promptly

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

I received enough individual attention from my therapist

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

My clinician communicated with my doctor regarding my therapy process

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Please rate the improvement in your condition due to physical therapy

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Cleanliness of facility

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Atmosphere

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Equipment type of availability

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

Parking

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

What is your overall impression of Total Physical Therapy?

	1	2	3	4	5

1 is Very Satisfied, 5 is Very Dissatisfied

What could we have done to make your visit better?
Would you refer someone to Total Physical Therapy?

Yes No
Would you recommend that your physician refer patients to Total Physical Therapy?

Yes No
Can we share your comments as testimonials or with your referring physician?

Yes No
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Optional - Contact Email
Optional - Comments
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