Date

Patient Name (optional)

Sex
MaleFemale

Age

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

Above Knee Prosthesis (AK)AFOBelow Knee Prosthesis (BK)Compression StockingFracture Brace/BootHip BraceKAFOKnee/Elbow ImmobilizerNeck Brace

*

Scoliosis BraceShoe InsertShoesSMOSoft Back Brace (corset)Soft Wrist/Hand BraceTLSO/LSO (Post-op back brace)UCBUpper Extremity Prosthesis

1. How long after calling for an appointment were you scheduled to be seen?
ImmediatelyLess than one weekMore than one weekMore than two weeks

2. Were you seen within 15 minutes of your scheduled time?
YesNo

3. In your opinion, was the staff friendly & polite at all times?
YesNo

4. When calling the office how long were you placed on hold?
0-30 seconds30 seconds-1 min1-2 minmore than 2 min

5. How well were the financial aspects of your care explained to you?
Very wellSomewhat wellNot well

6. Was the prescribed device received in the time communicated to you?
YesNo

7. At time of delivery, was the fit and function of the finished device:
ExcellentSatisfactoryUnsatisfactory

8. Did the device need to be remade?
YesNo

9. The workmanship & appearance of the finished device is:
ExcellentSatisfactoryUnsatisfactory

10. In your opinion, did the practitioner possess the necessary skills to provide you with the required device?
YesNoUnsure

11. Did you receive specific instructions from the practitioner?
YesNo

12. Were you scheduled for a follow-up appointment at time of delivery?
YesNo

13. Were patient waiting and treatments areas well-maintained?
YesNo

14. Would you use these services again?
YesNo

15. Are the office hours convenient?
YesNo

16. Would you recommend these services to others?
YesNo

17. How would you rate the value of the service(s) delivered to you?
Very valuableSomewhat valuableNot valuable

Any additional comments/observations? Please provide comments below:

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