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)