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 welcomed warmly and was the receptionist attentive to your needs? YesNo 2.) Was the receptionist knowledgeable about all our services in the office? 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 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.) How did you initially learn about the Roselle Center for Healing? Please check all that apply. ReferralWMAL 105.9 FMGoogle SearchSpecial EventSocial Media (Facebook, Instagram, Twitter etc.)Other 11.) Overall, please rate the quality of the service that you received during this visit. Very Good ★★★★★Good ★★★★Neutral ★★★Poor ★★Very Poor ★ 12.) 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
