Thank you for participating in this survey. Your experience and perspective are invaluable to the Roselle Center for Healing. Please complete so we may continue to make improvements. Your Name* Your Email* 1.) Were you always welcomed warmly by our front desk and are they attentive to your needs? YesNo 2.) Was our front desk staff knowledgeable about all our services in the practice? YesNoN/A 3.) How long did you have to wait in the lounge for your appointment? Less than 5 minutes5-15 minutesMore than 15 minutes 4.) How long did you have to wait in the exam room for your doctor or therapist? Less than 5 minutes5-15 minutesMore than 15 minutes 5.) How many minutes did you wait in line and complete your transaction? Less than 5 minutes5-15 minutesMore than 15 minutes 6.) What was the duration of your entire visit? Less than 30 minutes30-60 minutesMore than 60 minutes 7.) Please rate the cleanliness of the office. Extremely cleanSomewhat cleanNot clean at all 8.) How would you rate the following to describe your experience with your doctor/provider? Patience: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ Listened carefully/responsive: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ Approachable: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ Knowledgeable/Confident: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ Explained Diagnosis and Initial Treatment: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ Outlined Long-term Treatment Plan & Expectations: Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ 9.) What is the main service that interests you in the practice? Please check all that apply. Applied KinesiologyChiropracticAcupunctureNutritionMassage TherapyOther Modality 10.) Were you made aware that the Roselle Center for Healing can create financial arrangements to meet your budgetary needs? YesNo 11.) Are there any other problems that may have arisen while you were in our office that we did not cover? If this were your business, what improvements/changes would you make? Please let us know in the comments box: 12.) Overall, please rate the quality of the service that you received during this visit. Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ 13.) Would you recommend this office to a colleague, friend, or family member? YesNo If no, please let us know why in the comments box below. Would you like to be contacted by our Patient Advocate regarding any issues that may help us improve? If yes, please provide your phone number: Δ
