We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services and you can enter as much information as you want. All responses will be kept Confidential. Thank you for your time.

Date of Service ... *

Which office location? 4116 W. Craig Road 9355 W. Flamingo Road *

What type of service did you receive from Advanced Chiropractic Specialists? Consultation Routine Adjustment Auto Injury Work Related Injury Sports Injury *

How do you think we are doing? Excellent Average Needs Improvement

Ability to get in for an appointment at ACS? Excellent Average Needs Improvement

How was the patient representative who made your appointment? Excellent Average Needs Improvement

The responsiveness and politeness shown by our front desk? Excellent Average Needs Improvement

The amount of time of your treatment? Excellent Average Needs Improvement

Did the doctor answer your questions? Excellent Average Needs Improvement

Was the office neat and clean? Excellent Average Needs Improvement

Did the doctor listen to your requests? Excellent Average Needs Improvement

The overall care provided to you? Excellent Average Needs Improvement

Keeping my personal information private? Excellent Average Needs Improvement

Would you recommend us to a friend and/or relative? Yes No

What did you like best about our office?

What did you like least about our office?

Would you like a manager to contact you to discuss any concerns or questions? Yes No

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