1. Your age: Years    2. Your sex:  Female Male

    3.  Your case was: Auto Injury Post-surgical Work Related

    4. How did you learn about this facility? (Check all that apply.)

           Physician A Friend A Former Patient I am a Former Patient Insurance Company Recommendation Telephone Book / Yellow Pages Website Other......

     5. Please check the body part(s) for which you received physical therapy.

          Ankle / Foot Balance / Dizziness / Vertigo Knee Hip Back Neck Shoulder Hand / Elbow / Forearm

 Pease rate your degree of satisfaction with each of the following statements

  1. My physical therapist and staff are courteous and professional. Excellent Good Average Poor Very Poor

   2. Appointments were scheduled at convenient times. Excellent Good Average Poor Very Poor

  3. My treatment was a benefit for my condition. Excellent Good Average Poor Very Poor

   4. My first visit was scheduled at my earliest availability. Excellent Good Average Poor Very Poor

   5. Friendly staff greeted me promptly when I arrived for treatment. Excellent Good Average Poor Very Poor

   6. My physical therapist explained my condition to my satisfaction. Excellent Good Average Poor Very Poor

   7. The hours of the clinic fit my schedule well. Excellent Good Average Poor Very Poor

   8. I would recommend this facility to others. Yes No

   9. I would return to this facility if I required physical therapy services. Yes No

   10. My overall experience at Summit Physical Therapy was satisfying. Excellent Good Average Poor Very Poor

   Your Praises and Comments are important to us!  Please let us know what they are.

My name is:   My email address is:   (Optional)

I would like to know more about  Neck pain  Hip pain  Knee pain Shoulder pain  Lower back pain

Hand Therapy   Sport Fitness Programs  Balance and Dizziness treatment   Other