Evaluation Form

Customer Satisfaction Questionnaire
Please take a minute to fill out this simple survey form.
We appreciate your comments which will help us improve our services.

* denotes a required field

Your Name*

Email Address*

Name of Therapist

PERSONAL RELATIONS SKILLS

Which of the following best describes the bed side manner of your therapist.

Courteous	Friendly	Helpful	Polite
Rude	Indifferent	Uncommunicative	Curt

Did your therapist conduct himself/herself in a professional manner?

COMMUNICATION SKILLS

Did you find it easy and convenient to schedule appointments?

Yes

No

Were clear, concise, unambiguous explanations provided? Were medical terms explained?

On a scale of one to ten, how would you rate the knowledge, competence and
professional skills of your therapist? (1= poor - 10= excellent)

SESSION EXPERIENCE

On a scale of one to ten, how would you describe your
physical comfort level during the irrigation process? (1= intolerable - 10 = tolerable)

1

2

3

4

5

6

7

8

9

10

On a scale of one to ten, how would you describe your overall comfort level with colon irrigation?
(1= totally uncomfortable - 10 = very comfortable)

1

2

3

4

5

6

7

8

9

10

Describe the results you experienced after a series of colonics.

PRICING

Did you research the price structure for Colon Irrigation?

How would you rate the cost of our services.

Yes No

RECOMMENDATIONS

Would you recommend us to an acquaintance?

If yes, who? We would be glad to forward our brochure or other literature to your contact via email or regular mail.

Yes No

How did you
find us?

How would you describe your overall
level of satisfaction with our services?

How would you describe your overall experience with us? Feel free to share your testimonial.

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