Please enable JavaScript in your browser to complete this form.Patient Name (Optional)Date of Appointment1. Upon arrival, how would you rate your experience with our administrative staff?Friendly/HelpfulPleasantRudeNot acknowledgedNo receptionist2. Were your co-pays and/or deductible explained to you?YesNo3. Did you discuss your goals and objectives related to your care with your provider?YesNo4. How satisfied are you with your device(s)?SatisfiedMostly satisfiedNeutralMostly dissatisfiedDissatisfied5. Please rate the training you (or your caregiver) received about your device(s)?ExcellentVery goodGoodFairPoorI received no training6. If you had any questions, problems, or concerns about your care, were they addressed in a timely manner?YesNoI had no questions7. Please rate your overall satisfaction with the care you received at our practice.SatisfiedMostly satisfiedNeutralSomewhat dissatisfiedMostly dissatisfied8. Would you recommend our practice to your friends or family if they had a need for our services?YesNoNot sure9. FOR PROSTHETIC PATIENTS ONLY. Using the below slider, how comfortable is your socket? Selected Value: 0 (0 to 10 scale with zero being no pain and 10 being very painful.)10. Additional comments:Would you like for us to contact you? If so, please provide your name and phone number.FirstLastEmail *EmailSubmit Printable Patient Satisfaction Survey Form
