Free Seminars and Education on Acupuncture  
  Health Problems PATIENT SATISFACTION SURVEY  
  What Health Issues
can Acupuncture Treat?
 
Energy
  Chinese energy hand, abstract meridian points, painted with Chinese characters.  
  Chinese Energy Hand  

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TAKE OUR PATIENT SATISFACTION SURVEY

All of us at the Acupuncture and Chinese Medical Center want to make sure you have benefited from the treatments you have received. Please give us your candid feedback on your visits to our clinic, as we are always striving to improve.

We respect your privacy. All information is kept in strict confidence and will only be used to assist in improving your health. This information will never be shared or sold.

Please fill out the survey as accurately as possible and Submit when complete.
You can be anonymous, as your name and email are optional.

Name:  Email: 

How many treatments did you receive from our clinic? 


Please evaluate your experience at our clinic.

How would you rate the overall quality of care you received at our clinic?
Very Poor Poor Fair Good Excellent

Was the office staff friendly, courteous and helpful?
Very Poor Poor Fair Good Excellent

How would you rate the cleanliness of the clinic waiting room, reception area and exam rooms?
Very Poor Poor Fair Good Excellent

How would you rate how well the acupuncturist listened to what you had to say?
Very Poor Poor Fair Good Excellent

How would you rate how well the acupuncturist answered your questions?
Very Poor Poor Fair Good Excellent

How would you rate how well the acupuncturist offered advice on ways you can avoid illness and stay healthy?
Very Poor Poor Fair Good Excellent

Were the acupuncture treatments helpful for your chief complaint?
No Yes

Please choose the best option that describes the reason for stopping acupuncture treatment.
Complaint Gone Financial Time No Relief

Would you refer a friend to the Acupuncture and Chinese Medical Center?
No Yes

Comments or Suggestions