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Patient Satisfaction Survey

Your response to this evaluation form is extremely important to us. Its purpose is to help us monitor the quality of our patient care. Your answers to these questions will be kept strictly confidential. If you have any additional comments, please provide those at the bottom of the form.

Patient Name (optional):

Date:

Sex: Male Female Age:

Office Location:

What type of service did you receive? (Select all that apply)

Neck brace	AFO	Shoe insert
Hip brace	KAFO	Compression stocking
Fracture brace/boot	SMO	UCB
Soft back brace (corset)	Below Knee Prosthesis (BK)	Soft wrist/hand brace
Knee/elbow immobilizer	Above Knee prosthesis (AK)	Shoes
TLSO/LSO (Post-op back brace)	Upper Extremity Prosthesis	Scoliosis brace

How long after calling for an appointment were you scheduled to be seen?
Immediately
Less than one week
More than one week
More than two weeks

Were you seen within 15 minutes of your scheduled time? Yes No

In your opinion, was the staff friendly & polite at all times? Yes No

When calling the office how long were you placed on hold?
0-30 seconds
30 seconds-1 min
1-2 min
more than 2 min

How well were the financial aspects of your care explained to you?
Very well
Somewhat well
Not well

Was the prescribed device received in the time communicated to you?
Yes No

At time of delivery, was the fit and function of the finished device:
Excellent
Satisfactory
Unsatisfactory

Did the device need to be remade? Yes No

The workmanship & appearance of the finished device is:
Excellent
Satisfactory
Unsatisfactory

10.

In your opinion, did the practitioner possess the necessary skills to
provide you with the required device? Yes No Unsure

11.

Did you receive specific instructions from the practitioner? Yes No

12.

Were you scheduled for a follow-up appointment at time of delivery?
Yes No

13.

Were patient waiting and treatments areas well-maintained? Yes No

14.

Would you use these services again? Yes No

15.

Are the office hours convenient? Yes No

16.

Would you recommend these services to others? Yes No

17.

How would you rate the value of the service(s) delivered to you?
Very valuable
Somewhat valuable
Not valuable

Any additional comments/observations? Please provide comments below