Patient Satisfaction Survey:

We want you to have the best experience possible.  Please take a minute to complete our patient survey.  All information is for our use only and will be kept confidential.

Your age: Sex:
Which rehab specialist did you visit:
(if you're not sure of their name, please select PT or OT)
How did you hear about our office?

Please select the response which you feel most applies to the statements given:
The receptionist and/or billing department at the front desk:
1) The front office staff was courteous and helpful

2) It was easy to schedule all of my appointments

3) Staff offered assistance in resolving any problems

4) The front office staff was easily available by phone

5) The billing process was explained to me within the first visit

6) My insurance was explained to me within the second visit

Your therapist
7) My therapist was courteous

8) I was seen within 15 minutes of my appointment time

9) I was satisfied by the treatment provided by my therapist

10) My therapist understood my problem or condition

11) I was satisfied with the overall quality of my therapy care

12) My home program was clearly explained

13) My privacy was protected during my therapy care

14) I felt treated with dignity, respect and confidentiality

15) I would recommend Chestertown Physical Therapy to family and friends

16) Overall I was satisfied with my experience with my therapy and the facility

Additional Comments:

Your Name(optional):



If you have not previously completed an application, please download the forms below, fill them out, and bring them with you to your appointment.  You will need to submit completed forms before your first appointment.

Document Name: Word File PDF
Patient Information Form
Clinical Intake Form

Chestertown Physical Therapy/AquaFit | 818 High Street | Suite 1 | Chestertown, Maryland 21620
phone: 410.778.6565 | fax: 410.778.6536 | email:

hours of operation: 8:00am - 5:00pm Monday - Friday

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