Name
Email
Phone
Please answer the following:
If you had important questions regarding your condition or treatment, were you able to find someone to answer your questions?
Yes, always    Yes, sometimes    No    I didn’t have any questions
Were the answers that staff provided to your questions presented in a way that you could understand?
Yes, always    Yes, sometimes    No    I didn’t have any questions
How would you rate the skills of our staff in meeting or exceeding your expectations?
Excellent    Very Good    Good    Fair    Poor
Did you feel that you were treated with respect and dignity?
Yes, always    Yes, sometimes    No
Overall, how satisfied were you with the treatment and care you received at Twin Cities Pain Clinic?
Very satisfied    Somewhat satisfied    Somewhat dissatisfied    Very dissatisfied
Would you recommend Twin Cities Pain Clinic to your family or friends?
Yes, definitely    Yes, probably    No
If no, why not?
Do you have further comments or impressions that you would like to share?