Patient Satisfaction Form

  1. Your satisfaction is important to us. We ask that you please complete the following survey. Thank you.
  2. Were you able to schedule a convenient appointment?
  3. When you first arrived at our office, how would you rate your greeting by our reception staff?
  4. How comfortable and clean was the waiting area?
  5. Respecting your scheduled appointment time, were you seen:
  6. Did we explain your financial obligations?
  7. How would you rate the knowledge, care and attention that the practitioner provided to you during your visit?
  8. Did you and our professional staff discuss your goals and objectives as you go about your daily activities?
  9. Did you recieve your device(s) within the time frame your practitioner outlined?
  10. How satisfied are you with your device?
  11. How comfortable is the socket/device?
  12. How useful were the instructions we provided regarding the use and care of your device?
  13. Were you instructed about the purpose and function of the device?
  14. Were you instructed about the proper cleaning of the device?
  15. Were you instructed about the potential risks, benefits and precautions associated with the device?
  16. Were you instructed on how to inspect your skin for signs of trouble?
  17. Were you instructed about when and to whom to report changes in physical condition or general health?
  18. How would you rate the training you (or the person who takes care of you) received regarding the device you recently received?
  19. Were you instructed about whom to contact if a problem develops?
  20. If you had any questions, problems or concerns about your prosthesis, were they addressed in a timely manner?
  21. Do you use your device on a daily basis or some other frequency?
  22. If you do not continue to use it, is this due to a problem with the device?
  23. Please rate your overall satisfaction with the care you received.
  24. Would you recommend us to your friends or family if they were in need of similar services?
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