En Español | Text Size

Patient Satisfaction Survey

Please complete the following form being as specific as possible. Your feedback is very important to us.

Practitioner's Name:

Service Received:

/ /

Comments: If you answered dissatisfied or very dissatisfied on any question, please explain how we can improve in these areas

Would you like our staff to contact you to set another appointment?

Yes

If Yes, please enter your name and phone number

Name:

Phone:

- -

How did you find us?

How satisfied were you in the following areas?		Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
The Practitioner
1.	The amount of time you waited to see your practitioner.
2.	The friendliness and professionalism of your practitioner.
3.	The amount of time your practitioner spent with you.
The Orthosis/Prosthesis
1.	Satisfaction with the overall quality, fit and comfort of your device?
2.	The completion of your device in a timely manner?
3.	The quality of information you were given on how to use, clean and care for your device?
Our Staff
1.	Were you able to schedule a convenient appointment?
2.	The friendliness and professionalism of our office staff.
3.	The explanation of our billing and payment policies.
General
1.	The appearance and cleanliness of our waiting area and patient/fitting room.
2.	Your overall satisfaction with our company.