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  Patient Satisfaction Survey

Thank you for taking the time to fill out our customer satisfaction survey.  We appreciate your feedback.  Any comments will help us to better serve you in the future.

Patient First Name
Patient Last Name
Your First Name
Your First Name
Mailing Address
City
State
Zip
Telephone Number
Patient Age
Please rate how much you agree or disagree with the following statements
My appointment was scheduled in a reasonable
amount of time and the person with whom I spoke
with was courteous and helpful
I was seen within 15 minutes of my appointment
and if not, the reason for the delay was
explained to me
I found the waiting and treatment areas clean
and well maintained
The services provided to me were delivered in
a reasonable amount of time
Considering its limitations, I found the fit and
function of my orthosis / prosthesis satisfactory
I have found that my orthosis / prosthesis
is adequate for my needs
The appearance and workmanship of my
orthosis / prosthesis is to my satisfaction
The Orthotist / Prosthetist who provided
my service, was very knowledgeable and skillful
Overall, I was satisfied with the quality
treatment I received from Services
I received specific recommendations and/or
instructions on proper care and use
of my orthosis / prosthesis
I would recommend this provider to
others requiring such services
What areas could we improve upon?
Would you like to speak to someone
about the services provided?
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