Name *or leave blank for anonymity First Name Last Name Reason for therapy: * Please rate your experience: * My symptoms were relieved. Strongly Disagree Disagree Neutral Agree Strongly Agree The clinic staff was very helpful. Strongly Disagree Disagree Neutral Agree Strongly Agree The clinic staff was professional. Strongly Disagree Disagree Neutral Agree Strongly Agree The facility was comfortable, clean and equipment was satisfactory. Strongly Disagree Disagree Neutral Agree Strongly Agree Please rate your overall experience on a scale of 1-5. * (1 being bad, 5 being very good) 1 2 3 4 5 Please describe your experience or leave additional comments: Can we feature your review? * Yes No Thank you! Your feedback will help us to better serve our patients.
