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Evaluation Form
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13
Questions
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1
Where did you here about us?
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Please Select
Internet
Friends or family
Social media
Flyer or business card
Other
Please Select
Please Select
Internet
Friends or family
Social media
Flyer or business card
Other
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2
Website
What did you think of our website
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Navigation
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Ease of use
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Responsiveness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Content
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Navigation
Ease of use
Responsiveness
Content
Not Satisfied
Row 0, Column 0
Somewhat Satisfied
Row 0, Column 1
Satisfied
Row 0, Column 2
Very Satisfied
Row 0, Column 3
Not Satisfied
Row 1, Column 0
Somewhat Satisfied
Row 1, Column 1
Satisfied
Row 1, Column 2
Very Satisfied
Row 1, Column 3
Not Satisfied
Row 2, Column 0
Somewhat Satisfied
Row 2, Column 1
Satisfied
Row 2, Column 2
Very Satisfied
Row 2, Column 3
Not Satisfied
Row 3, Column 0
Somewhat Satisfied
Row 3, Column 1
Satisfied
Row 3, Column 2
Very Satisfied
Row 3, Column 3
1
of 4
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3
Pick one from the source you used
*
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Very poor
Not that bad
somewhat
good
Perfect
Online
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
24/7 booking line
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Enquiries line
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Online
24/7 booking line
Enquiries line
Very poor
Row 0, Column 0
Not that bad
Row 0, Column 1
somewhat
Row 0, Column 2
good
Row 0, Column 3
Perfect
Row 0, Column 4
Very poor
Row 1, Column 0
Not that bad
Row 1, Column 1
somewhat
Row 1, Column 2
good
Row 1, Column 3
Perfect
Row 1, Column 4
Very poor
Row 2, Column 0
Not that bad
Row 2, Column 1
somewhat
Row 2, Column 2
good
Row 2, Column 3
Perfect
Row 2, Column 4
1
of 3
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4
Select relevant box for each one
*
This field is required.
Very poor
Not that bad
Somewhat
Good
Perfect
Professionalism
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Knowledge
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Compassion
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Communication
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Professionalism
Knowledge
Compassion
Communication
Very poor
Row 0, Column 0
Not that bad
Row 0, Column 1
Somewhat
Row 0, Column 2
Good
Row 0, Column 3
Perfect
Row 0, Column 4
Very poor
Row 1, Column 0
Not that bad
Row 1, Column 1
Somewhat
Row 1, Column 2
Good
Row 1, Column 3
Perfect
Row 1, Column 4
Very poor
Row 2, Column 0
Not that bad
Row 2, Column 1
Somewhat
Row 2, Column 2
Good
Row 2, Column 3
Perfect
Row 2, Column 4
Very poor
Row 3, Column 0
Not that bad
Row 3, Column 1
Somewhat
Row 3, Column 2
Good
Row 3, Column 3
Perfect
Row 3, Column 4
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of 4
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5
Select relevant box
*
This field is required.
Very poor
Not that bad
Somewhat
Good
Perfect
Facilities
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Facilities
Very poor
Row 0, Column 0
Not that bad
Row 0, Column 1
Somewhat
Row 0, Column 2
Good
Row 0, Column 3
Perfect
Row 0, Column 4
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6
Overall, were you satisfied with the facilities we use?
*
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Yes
No
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7
Please add any additional comments here?
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8
Would you recommend Empire Physiotherapy to a friend?
*
This field is required.
Yes, definitely
Maybe, if it was cheaper
No, never
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9
Is there any aspect of our service that you would like us to change?
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10
Any final comments?
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11
Your Name
First Name
Last Name
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12
E-mail
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13
Phone Number
Area Code
Phone Number
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