Customer Review Form

Client / Patient Experience Feedback
Thank you for the privilege of assisting you in your health journey. To help our growth in providing care to our patients, please take the time to give us feedback regarding our service. With your consent, your feedback could be posted on social media as a review of our service.
Date

DayMonthYear
Date
Customer's Name

First NameLast Name
Customer's Email
example@example.com
Which practitioner did you see?
How content are you with our service?
Comments, suggestions, or feedback
Do you consent to sharing your feedback on social media eg Google Reviews? If you click YES, you will be taken to Google Reviews - please DO NOT disclose any clinical treatments or conditions as this is against the law. You can share about your general experience.
If you do not have a Gmail account, when you’re prompted to sign in, click on “Create account.” Next, choose “for myself” or “for my business.”

The next page will give you the option to use your current email address instead of signing up for a Gmail address. As long as you have a valid email account to use, you can leave a Google review without using a Google email address.
Signature
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Client / Patient Experience Feedback