Customer Satisfaction Survey Template

Question Title

* 1. How likely is it that you would recommend our practice to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

0

1

2

3

4

5

6

7

8

9

10

0

1

2

3

4

5

6

7

8

9

10

Question Title

* 2. Overall, how satisfied or dissatisfied are you with Dr. Safko's Chiropractic and Massage services?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

Other (please specify)

Question Title

* 3. Which of the following words would you use to describe our services? Select all that apply.

Reliable

High quality

Useful

Unique

Good value for money

Other (please specify)

Question Title

* 4. Would you like to receive information about our Massage Services?

Yes

No

Question Title

* 5. Would you be interested in Acupuncture Services at our office?

Yes

No

Question Title

* 6. Would you like to receive our monthly newsletter on health and fitness related to your chiropractic care?

Yes

No

Question Title

* 7. What topics are you most interested in?

Orthopedic and Chiropractic News

Fitness and Physical Therapy Tips

Nutrition Choices and Recipes

Question Title

* 8. Are you familiar with Dr. Safko's new X-Factor Belt™?

Yes

No

Question Title

* 9. Send us your name and email to learn more about the X-Factor Belt™.

Name

Email Address

Question Title

* 10. Please send us your name and email to receive $25. off your next Extended Massage Therapy session.

Name

Email Address