JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Welcome Survey-Rio
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date
*
MM
/
DD
/
YYYY
EMR #
*
Your answer
How did you hear about Aptus Therapy Services?
*
Recommendation from Doctor
Insurance Plan
Community Events
Newspaper Advertisement
Location
Referred by Friend
Television
Internet
Was your appointment scheduled in a timely manner?
*
Yes
No (if not, explain in other)
Other:
Required
Were your insurance benefits explained to you?
*
Yes
No
Did you have any misunderstandings regarding insurance benefits
*
Yes (if so, explain in other)
No
Other:
Required
Once completing the appropriate forms, how long did you wait before being seen by your therapist?
*
0-5 min
5-10 min
10-15 min
15-20 min
20+ min
Did you receive a tour of the facility?
*
Yes
No
Was your initial experience pleasant?
*
Yes
No
If no, explain what would have made your experience more pleasant:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
