Q1. How did you hear about our clinic? *

Referral by family or friend	MD referral	Advertising
Yellow Pages	Online	Lecture
Saw us at an event	Other

Q2. Have you had Physiotherapy / Massage Therapy/ Athletic Therapy Treatment Before?

Q3. What was your first impression of our clinic?

Q4. Which of our clinics did you attend? *

Aurora	Markham	Toronto Cricket Club (members only)
Pickering College (students and staff)	Apotex Employees Clinic	Honsberger Golf at Magna Golf Course

Q5. How quickly we scheduled your first visit: *

Q6. Friendliness of the staff who greeted you and took care of you at your first visit : *

Q7. How well your therapist clearly explained your condition and future treatment plan : *

Q8. How well your insurance questions were answered : *

Poor	Fair	Good
Very Good	Excellent	Not Applicable

Q9. How well your therapist explained your home exercise program : *

Q10. What other services could you be interested in the future?

Custom orthotics	Custom braces	Sports Vision training
Baseline concussion testing	Honsberger Health Index injury prevention screen	Running gait analysis
Sports specific training	Ergonomic evaluations	Business wellness seminars
Group Strength and Conditioning Classes	None

Q11. Add other comments or insights below that could help us improve your first experience with our clinic.

Q12. If we were to add further services to our practice, in which of the following would you be interested ? *

Naturopath	Homeopath	Chiropractor
Sports medicine doctor	Executive health screening	Vaccination/ flu clinics
Education seminars	Nutritionist

Q13. If you would like to be contacted regarding your responses, please complete the following information:

Name	*
Phone number	*
Email address

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