| Name: |
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| Email: |
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| Your visit was on? |
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| Overall rating for the chiropractor |
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| How satisfied were you with the time you had to wait for an appointment? |
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| Were you treated with dignity and respect as a patient of our clinic? |
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| How satisfied were you with the outcome of your treatment? |
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| What I liked? |
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| What could have been improved? |
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| Any other comments? |
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