Patient Feedback Form

* Required

First Name

Last Name

Email Address

Home Phone Number

Which location did you receive your therapy treatments? *

The clinic was clean and comfortable.

You were able to make appointments at times that worked for you.

You were happy with the explanation you received about your insurance coverage.

Your therapist was knowledgeable about your particular type of therapy, and was helpful in answering all your questions.

You are doing everything that your therapist asked you to do to help yourself get better.

If your friends or family needed therapy, you would recommend Northern Physical Therapy.

Now that your therapy is complete, how do you feel?

Did you choose Northern, or did your doctor recommend you receive your treatment at Northern?

Additional Comments?

May we use your feedback in future marketing materials? *

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