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Physical Therapy Survey

Tell Us How We Are Doing

Submit Your Feedback

We are interested in learning from our patients how we might improve or enhance our services. Please take a few minutes to complete this questionnaire. Any additional input is welcome at the bottom of the survey in the "comments" section. When you click "submit" your completed survey will be emailed to our practice.

Required fields are marked with *

Gender

FemaleMaleOther

Which location did you visit?

Your Therapist's Name

How did you learn about this facility?

Physician

Friend

Telephone Book

Former Patient

Online

Other

Was this your first experience with physical therapy?

YesNo

Was this your first experience with this facility?

YesNo

Please check the location of the problem for which you received physical therapy. Check all that apply.

Neck

Lower back

Shoulder

Elbow

Hip

Foot

Hand

Knee

Vertigo/Vestibular Rehabilitation

Please call to set up an appointment.

Before We Begin

Are you a current patient at Central Ohio Primary Care?

Please Note

This form is used for COPC's New Patient Placement team to help you find a new COPC doctor. It is not intended to request an appointment for a COVID-19 vaccination. Please click here to view the latest COVID-19 updates from COPC.

Yes

Patient Information

Enter your first name, phone number, zip code, and insurance below.

First Name

Phone Number

Insurance

Zip Code

Do you have a Medicare or Medicare Advantage plan?

YesNo

Select a Preferred Date and Time

Select a preferred date and time for an appointment.

Preferred Day of Week

Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

Preferred Time

Confirm Details

Please verify your details are correct.

Patient Details

Name

Phone Number

Zip Code

Insurance

Do you have a Medicare or Medicare Advantage plan?

Preferred Appointment Day

Preferred Appointment Time

Best Time to Call Day

Best Time to Call Time

Your Request Has Been Submitted

A member of our New Patient Placement team will call you within 1 business day to assist you with scheduling your appointment. Please wait for our team to contact you before arriving to your appointment. If you have questions prior to our phone call, please dial (614) 326-4646, Monday — Friday, 7:30am to 5:00pm.

Patient Details

Add Us to Your Contacts

Download our contact card below so you don’t miss our call to schedule your appointment.

For Mobile Users Tap the download button below to add us to your contacts.

Download Contact Card

For Desktop Users Scan the QR code with your mobile phone to add us to your contacts.

For Current Patients

Please call your physician's office to set up an appointment.

Provider Overview

Provider Details

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Location Details

Are You a Current Patient?

Are you a current patient at Central Ohio Primary Care?

Best Time For Us To Call You

Select a preferred time range that is most convenient for us to call you and schedule your appointment.

Preferred Day of Week

Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

Preferred Time

For Current Patients

Please call this physician's office to set up an appointment.

New Patient Scheduling

New Patients can either self schedule if it an option or request an appointment and our scheduling offices will contact you.

Request an Appointment

Self Scheduling

Established Patient Scheduling

Existing patients can either schedule an appointment through MyChart or call the physicians office for scheduling.

Schedule with MyChart

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Physical Therapy Survey

Tell Us How We Are Doing

Submit Your Feedback

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