Patient Satisfaction Evaluation
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1. Patient Satisfaction
*
1
. Patients Name.
Patients Name.
2
. Please rate the professional manner in which our Practicioner presented himself.
Please rate the professional manner in which our Practicioner presented himself.
Poor
Fair
Good
Excellent
Your additional comments are welcome:
3
. How clear were the instructions on the care and use of your device?
How clear were the instructions on the care and use of your device?
Poor
Fair
Good
Excellent
Your additional comments are welcome:
4
. Please rate overall fit, comfort, and quality of your device.
Please rate overall fit, comfort, and quality of your device.
Poor
Fair
Good
Excellent
Your additional comments are welcome
5
. The amount of time our practicioner spent with you was sufficent to answer all of your questions and concerns.
The amount of time our practicioner spent with you was sufficent to answer all of your questions and concerns.
Poor
Fair
Good
Excellent
Your additional comments are welcome:
6
. Were you able to get a convenient appointment time and date?
Were you able to get a convenient appointment time and date?
Poor
Fair
Good
Excellent
Your additional comments are welcome:
7
. How helpful was office personel in providing information?
How helpful was office personel in providing information?
Poor
Fair
Good
Excellent
Your additional comments are welcome:
8
. Please rate your overall experience with ORTHOLOGIX.
Please rate your overall experience with ORTHOLOGIX.
Poor
Fair
Good
Excellent
Your additional comments are welcome:
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