Online-Patient-Survey Date MM slash DD slash YYYY My email address is Please check the percent improvement you experienced with treatment. No Better 25-50% 51-75% 76-100% How soon were you able to make your first appointment? Same day Within 2 days Within 1 week Within 2 weeks Check the box that best describes your experience as it relates to the questions below.What did we do well with your care? (please write your comments in the box below)What could we have done better? (please write your comments in the box below)Would you use us again? Yes No Would you recommend us to a friend? Yes No Receiving the Rakita Tomsic PT monthly newsletter on fitness, injury prevention, and physical therapy makes me more likely to use you in the future. (check the response that is most appropriate) Yes No I don’t get your newsletter but would like to receive it. PhoneThis field is for validation purposes and should be left unchanged.