MyChiroClub Feedback Form

We would love to hear from you! Please take a moment to let us know about your experience at MyChiroClub. The areas marked with * are required.

Full Name

First Name Last Name

Phone Number

Area Code Phone Number

Date

E-mail

How did you hear about us? *

Drive By Referral Website Community Flyer

What do you think about our rates compared to competitors? *

	1	2	3	4	5

1 is Affordable, 5 is Too high!

How would you rate your overall experience so far with MyChiroClub? *

	1	2	3	4	5

1 is Needs Improvement, 5 is Awesome!

How would you rate our availability and office hours? *

	1	2	3	4	5

1 is Needs Improvement, 5 is Awesome!

Would you pay $20 extra in membership to have access to an automatic massage table each visit? *

Yes No

Have you referred a family member or friend to MyChiroClub? *

Yes No

Which type of adjustment do you prefer? *

Very mild force with instrument only Medium force with drops on table only Full Force with neck and low back Whatever it takes

Why do you get adjusted? *

Pain relief only Wellness care and prevention of illnesses Both of the above

What day of the week is best for you to get your weekly adjustment? *

Monday Tuesday Wednesday Thursday Friday Saturday

What time of the day is best for you to get your weekly adjustment? *

Early Morning (8:00am-10:00am) Late Morning (10:00am-1:00pm) Early Afternoon (1:00pm-3:00pm) Late Afternoon (3:00pm-6:00pm)

If you would like to change one thing at MyChiroClub, what would it be? *

How are we doing?