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CLIENT EXPERIENCE QUESTIONNAIRE


Our mission is to maintain a dedicated, caring, and knowledgeable team committed to providing exceptional client
services and Chiropractic Care. We strive toward this excellence through continuing education, technical advances, and compassionate care for all of our patients.

You can help us reach and maintain this level of service by sharing your chiropractic needs and expectations. By
completing this client survey, you will be a part of our team meetings, and be assured that your comments will be
discussed and acted upon. Thank you for your time and effort.

(Please Note: Your privacy is 100% assured.)

Requested Information

Your telephone experience: (check all that apply)
Your impression of our Receptionist (over the phone): (check all that apply)
Your impression of our Receptionist (in person): (check all that apply)
Your impression of our reception area: (check all that apply)
Your impression of our parking lot/grounds: (check all that apply)
Your impression of our website: (check all that apply)
Your impression of our Doctor: (check all that apply)

Additional Questions

If you would like us to contact you, please fill out the necessary information.