Patient Survey

Please complete the following form being as specific as possible (all entries are optional). Your feedback is very important to us.

Practitioner's Name: Date Services Rendered:
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
4. Satisfaction with the overall quality, fit and comfort of your device?
5. The completion of your device in a timely manner?
6. The quality of information you were given on how to use, clean and care for your device?
Our Staff
7. Were you able to schedule a convenient appointment?
8. The friendliness and professionalism of our office staff.
9. The explanation of our billing and payment policies.
10. The appearance and cleanliness of our waiting area and patient/fitting room.
11. Your overall satisfaction with our company.
Recommend?: Would you recommend us to a friend? Please tell us why or why not:
Comments: Any additional comments/observations? Please provide comments below:
Would you like our staff to contact you to set another appointment? Yes No  
If Yes, please enter your name and phone number Name: Phone:
How did you find us?

We Appreciate Your Business!