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	Patient Feedback
	Thank you for making Merrimack Valley Physical Therapy your choice for physical therapy and fitness services.  We value your feedback, and would welcome your comments. Please take a few minutes to complete this survey.

	Please indicate by writing in the response.
	Name (Not required):
	Referring Physician:
	Injury/Body Part:
	Gender:		Male Female
	Name of Your physical therapist:
	Please indicate the appropriate response.
	Did physical therapy help you?		Extremely Satisfied Satisfied Not Satisfied
	Did your therapist explain the types of treatment techniques you were receiving?		Extremely Satisfied Satisfied Not Satisfied
	Did you find the office/treatment areas comfortable?		Extremely Satisfied Satisfied Not Satisfied
	Did the therapist clearly communicate with you and your physician regarding your progress?		Extremely Satisfied Satisfied Not Satisfied
	Was the front desk staff helpful?		Yes No
	Were you able to schedule appointments at the times you most desired?		Yes No
	Would you recommend our practice to your family and friends?		Yes No
	Would you return to our practice if you required physical therapy services in the future?		Yes No
	Additional Comments:
	Thank you for your personal comments and feedback!