Patients Name

Name of person completing survey.

Telephone Number

Age of patient

Type of device worn


PLEASE RATE US ON A SCALE OF 1-5 WITH 5 INDICATING EXCELLENT AND 1 POOR
CIRCLE THE NUMBER YOU FEEL MOST APPROPRIATE

1. My appointment was scheduled in a reasonable amount of time and the person with whom I spoke with was courteous and helpful.
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2. I was seen within 15 minutes of my appointment and if not, the reason for the delay was explained to me.
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3. I found the waiting and treatment areas clean and well maintained.
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4. The services provided to me were delivered in a reasonable amount of time.
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5. Considering its limitations, I found the fit and function of my orthosis/prosthesis satisfactory.
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6. I have found that my orthosis/prosthesis is adequate for my needs.
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7. The appearance and workmanship of my orthosis/prosthesis is to my satisfaction.
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8. The Orthotist/Prosthetist who provided my service, was very knowledgeable and skillful.
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9. Overall, I was satisfied with the quality treatment I received from <> Services.
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10. I received specific recommendations and/or instructions on proper care and use of my orthosis/prosthesis.

11. I would recommend <<2002!2>> to others requiring such services.

12. What needs to be improved?

Would you like to speak to someone about the services provided.

Testimonial (Optional)


Our グッチ 財布 are skilled at helping patients of all グッチ 財布 激安, particularly young ones. グッチ 財布 アウトレット has been a passion and a focus at Lawalls since our inception in 1977. We are proud to グッチ 財布 アウトレット a full range of quality pediatric care from newborns, to グッチ 財布 メンズ 二つ折り. No matter if the problem is a birth グッチ 財布 人気, an injury, or an illness, were ready to help. - See more at: http://www.lawall.com/GUCCI.html