* 1. Patient Name:

* 2. Parent or Guardian of patient (if patient is under age 18):

* 3. Contact Phone Number:

* 4. Type of therapy patient was seen for:

* 5. Patient Since:

Purpose of this Survey This survey 
This survey is intended to help identify ways MECA Therapies can improve as a company, and as a way to asses how satisfied you were with the services that were provided to you or your child. Your feedback is very important to us and is crucial to our future success, so please be as honest as possible in your responses. Also know, that all gathered information is for internal purposes only and will not be disclosed or discussed with outside sources.  
Please answer the following questions to the best of your ability. If you are a parent filling out this survey please respond to the following questions as they pertain to your child and their treatment. 

* 6. Approximately how often did a MECA Therapist or Specialist see you?

Please rate the following items on a scale of 1-5 (1=very poor, 5=excellent). 

* 18. Availability of appointment times

* 19. Overall customer service from all MECA personnel

* 20. As a company, what are we doing well?

* 21. What can we do to improve?

Thank you for taking the time to fill out this survey. We wish you the best in all your future endeavors.