EmailMeForm
Thank you for taking the time to complete our customer satisfaction survey.
Your feedback is important, and we are always striving to improve our clinic experience.
How satisfied are you with your experience at Maple Health Care and Rehab?
 
Unsatisfied
1
2
3
4
5
6
7
8
9
10
 
Very Satisfied
How satisfied are you with your experience at Maple Health Care and Rehab?
 
Unsatisfied
1
2
3
4
5
6
7
8
9
10
 
Very Satisfied
How would you rate your experience with our therapists?
 
Poor
1
2
3
4
5
6
7
8
9
10
 
Excellent
How would you rate your experience with our front desk staff?
 
Poor
1
2
3
4
5
6
7
8
9
10
 
Excellent
Please provide any comments or feedback or a testimonial for our services:
I hereby give my consent for my testimonial to be used by the clinic
Only initials will be used to identify the client - no full names
Yes
No
Name
First
Last
Date Time
MM
/
DD
/
YYYY