Megan M. Marco, D.Ac., L.Ac. Feedback Form

Send Us Your Feedback
We'd like to continue to improve our services and our center to meet the needs of our diverse clientelle. Take just a few minutes out of your day to fill out this form and you will receive a free 10% off your next acupuncture treatment. Limited to the sender only, one time use per patient. We will send the gift certificate for the treatment bonus to your mailing address. We look forward to receiving your feedback!

Note: Use your mouse or the "tab" key to move from one question to the next on this form. When you are done making all of your selections and answering the questions, click the "Send Feedback" button or hit Return/Enter on your keyboard to send the form to us.

Your Name:

Your Email Address:

Newsletter:

Informative, fun and filled with great health information, the newsletter will be released soon. If you are interested, please indicate below what form of the newsletter you would like to receive.

Email Newsletter
Paper Newsletter

Your Mailing Address:

Street Address:
City:
State:
Zip Code:

Satisfaction

Are you able to get an appointment at a time you want?

Always
Usually
Sometimes
Seldom
Never

How would you rate the courtesy and consideration of the Stonington Natural Health Center Practitioners?

Excellent
Good
Average
Fair
Poor

At your last appointment, how long did you wait before seeing your practitioner?

Less than 5 minutes
5-10 minutes
10-15 minutes
Over 15 minutes

How would you rate the cleanliness of Stonington Natural Health Center?

Excellent
Good
Average
Fair
Poor

Any comments or a testimonial you would like to make about the center or the practitioners?

Practitioner/Treatment

At your last appointment, who treated you?

How well did your practitioner listen to you?

Excellent
Good
Average
Fair
Poor

How well did your practitioner explain what was being done and why during your treatment?

Excellent
Good
Average
Fair
Poor

How would you evaluate your practitioner for courtesy, care and respect toward you?

Excellent
Good
Average
Fair
Poor

Did the treatment your received make you feel better?

Much Better
Somewhat Better
No Change
Felt Worse

How good was your practitioner in evaluating your health condition and deciding what treatment you needed?

Excellent
Good
Average
Fair
Poor

Overall, how would you rate the practitioner who treated you?

Excellent
Good
Average
Fair
Poor

Any comments or a testimonail you'd like to make about your practitioner or treatment?

Herbs

Were the directions for taking your herbs clear, understandable and thorough?

Yes
No
Could be Clearer

Health Information

Is Dr. Megan Marco's website a good source of information on how you can live a healthy life?

Yes
No
Not Sure

Please rank (1 as the most important, 6 as the least important) how important the following resources are to you in helping you stay healthy:

	Brochures/flyers/books in the Stonington Natural Health Center waiting area
	Dr. Megan Marco's website (www.meganmarco.com)
	Talking with your practitioner during a treatment
	Calling Stonington Natural Health Center and talking to Megan
	Attending an educational event or seminar at Stonington Natural Health Center
	Other (please describe)

How would you rate the Stonington Natural Health Center in providing information and resources to help you lead a healthy life?

Excellent
Good
Average
Fair
Poor

Do you have any suggestions for Stonington Natural Health Center regarding natural health education?

About You

How long have you been coming to Stonington Natural Health Center?

Less than 6 months
6-12 months
1-2 years
Over 2 years

How did you hear about Stonington Natural Health Center?

From a news item or article
From the phone book (Qwest Dex, etc.)
Environmentally conscious yellow pages, ReDirect
From an advertisement
From the internet
From a friend, relative, or coworker
From health insurance material
From a card or brochure that I found at
Recommended by a health practitioner.
Their name:
Other (please describe)

In general, would you say your health is:

Excellent
Good
Average
Fair
Poor

Are you:

Male
Female

What is your age?

Under 18
18-25
26-35
36-45
46-55
56-65
66-75
Over 75

Please select the one that best describes your level of education:

Some high school
High school graduate
Some college
College Graduate
Post-Graduate work

What is your zip code?

If you could do just one thing to improve your experience with Stonington Natural Health Center, what would it be?

Please enter the letters in the image below into the box on the right
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