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Was this your first visit to our office? |
Yes
No
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What was the purpose of your visit? |
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How did you learn about Vital Energy? |
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On a scale of 1-5 with 5 being Excellent, please rate your visit with us.(1 – Poor, 2 – Fair, 3 – Good, 4 – Very Good, 5 – Excellent) |
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Ease of setting your appointment |
5
4
3
2
1
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Greeting by our front office personnel when you arrived |
5
4
3
2
1 |
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The ease of checking in and paying any monies due |
5
4
3
2
1
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Cleanliness/neatness of the waiting room |
5
4
3
2
1
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Friendliness of our office staff |
5
4
3
2
1
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Cleanliness/neatness of the facility |
5
4
3
2
1
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Length of time you had to wait before being called for your appointment |
5
4
3
2
1
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Friendliness of the therapist |
5
4
3
2
1
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Ability of therapist to put you at ease |
5
4
3
2
1
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The ease of checking out and making additional appointments |
5
4
3
2
1
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In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices, or
any other comments. |
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How likely is it that you would recommend our therapist to your family, co-workers, and friends? |
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Would you like to provide your contact information? |
Yes
No
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Name |
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Telephone Number |
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Email ID |
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Image Verification |
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