SCOPe Orthotics & Prosthetics Patient Survey

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We are commited to providing exceptional service. Your comments are important to us. Thank you for your time.

1. What type of product did you receive?

What type of product did you receive? Prosthetic

Orthotic

2. Where were you seen?

Where were you seen? Hospital

Doctor's Office

SCOPe Office

3. Your Appointment:

	Dissatisfied	Slightly Satisfied	Satisified	Very Satisfied	N/A
Ease of making appointments by phone?	*Your Appointment: Ease of making appointments by phone? Dissatisfied	Ease of making appointments by phone? Slightly Satisfied	Ease of making appointments by phone? Satisified	Ease of making appointments by phone? Very Satisfied	Ease of making appointments by phone? N/A
Appointment available within a reasonable amount of time?	Appointment available within a reasonable amount of time? Dissatisfied	Appointment available within a reasonable amount of time? Slightly Satisfied	Appointment available within a reasonable amount of time? Satisified	Appointment available within a reasonable amount of time? Very Satisfied	Appointment available within a reasonable amount of time? N/A
Were you offered other offices that might be more convenient when you scheduled your appointment?	Were you offered other offices that might be more convenient when you scheduled your appointment? Dissatisfied	Were you offered other offices that might be more convenient when you scheduled your appointment? Slightly Satisfied	Were you offered other offices that might be more convenient when you scheduled your appointment? Satisified	Were you offered other offices that might be more convenient when you scheduled your appointment? Very Satisfied	Were you offered other offices that might be more convenient when you scheduled your appointment? N/A
The efficiency of the check in process?	The efficiency of the check in process? Dissatisfied	The efficiency of the check in process? Slightly Satisfied	The efficiency of the check in process? Satisified	The efficiency of the check in process? Very Satisfied	The efficiency of the check in process? N/A
Waiting time in the lobby?	Waiting time in the lobby? Dissatisfied	Waiting time in the lobby? Slightly Satisfied	Waiting time in the lobby? Satisified	Waiting time in the lobby? Very Satisfied	Waiting time in the lobby? N/A

4. Front Office Staff:

	Dissatisfied	Slightly Satisfied	Satisfied	Very Satisfied	N/A
The courtesy and friendliness of the person who took your call?	*Front Office Staff: The courtesy and friendliness of the person who took your call? Dissatisfied	The courtesy and friendliness of the person who took your call? Slightly Satisfied	The courtesy and friendliness of the person who took your call? Satisfied	The courtesy and friendliness of the person who took your call? Very Satisfied	The courtesy and friendliness of the person who took your call? N/A
The helpfulness of the people who assisted you?	The helpfulness of the people who assisted you? Dissatisfied	The helpfulness of the people who assisted you? Slightly Satisfied	The helpfulness of the people who assisted you? Satisfied	The helpfulness of the people who assisted you? Very Satisfied	The helpfulness of the people who assisted you? N/A
Did the person who assisted you seem knowledgeable?	Did the person who assisted you seem knowledgeable? Dissatisfied	Did the person who assisted you seem knowledgeable? Slightly Satisfied	Did the person who assisted you seem knowledgeable? Satisfied	Did the person who assisted you seem knowledgeable? Very Satisfied	Did the person who assisted you seem knowledgeable? N/A

5. Our Communication:

	Dissatisfied	Slightly Satisfied	Satisfied	Very Satisfied	N/A
Your phone calls were answered promptly?	*Our Communication: Your phone calls were answered promptly? Dissatisfied	Your phone calls were answered promptly? Slightly Satisfied	Your phone calls were answered promptly? Satisfied	Your phone calls were answered promptly? Very Satisfied	Your phone calls were answered promptly? N/A
Effectiveness of our health information materials?	Effectiveness of our health information materials? Dissatisfied	Effectiveness of our health information materials? Slightly Satisfied	Effectiveness of our health information materials? Satisfied	Effectiveness of our health information materials? Very Satisfied	Effectiveness of our health information materials? N/A
Your ability to contact us after hours?	Your ability to contact us after hours? Dissatisfied	Your ability to contact us after hours? Slightly Satisfied	Your ability to contact us after hours? Satisfied	Your ability to contact us after hours? Very Satisfied	Your ability to contact us after hours? N/A
The timeliness of our response to questions, problems and concerns?	The timeliness of our response to questions, problems and concerns? Dissatisfied	The timeliness of our response to questions, problems and concerns? Slightly Satisfied	The timeliness of our response to questions, problems and concerns? Satisfied	The timeliness of our response to questions, problems and concerns? Very Satisfied	The timeliness of our response to questions, problems and concerns? N/A

6. Your Practitioner:

	Dissatisfied	Slightly Satisfied	Satisfied	Very Satisfied	N/A
Was your practitioner courteous and knowledgeable?	*Your Practitioner: Was your practitioner courteous and knowledgeable? Dissatisfied	Was your practitioner courteous and knowledgeable? Slightly Satisfied	Was your practitioner courteous and knowledgeable? Satisfied	Was your practitioner courteous and knowledgeable? Very Satisfied	Was your practitioner courteous and knowledgeable? N/A
Was willing to listen carefully to you and take the time to answer questions?	Was willing to listen carefully to you and take the time to answer questions? Dissatisfied	Was willing to listen carefully to you and take the time to answer questions? Slightly Satisfied	Was willing to listen carefully to you and take the time to answer questions? Satisfied	Was willing to listen carefully to you and take the time to answer questions? Very Satisfied	Was willing to listen carefully to you and take the time to answer questions? N/A
Explained things such as follow-up care in a way you can understand?	Explained things such as follow-up care in a way you can understand? Dissatisfied	Explained things such as follow-up care in a way you can understand? Slightly Satisfied	Explained things such as follow-up care in a way you can understand? Satisfied	Explained things such as follow-up care in a way you can understand? Very Satisfied	Explained things such as follow-up care in a way you can understand? N/A

7. Your Outcome:

	Dissatisfied	Slightly Satisfied	Satisfied	Very Satisfied	N/A
Are you satisfied with your device/service?	*Your Outcome: Are you satisfied with your device/service? Dissatisfied	Are you satisfied with your device/service? Slightly Satisfied	Are you satisfied with your device/service? Satisfied	Are you satisfied with your device/service? Very Satisfied	Are you satisfied with your device/service? N/A
Are you satisfied with the clinical function of your device?	Are you satisfied with the clinical function of your device? Dissatisfied	Are you satisfied with the clinical function of your device? Slightly Satisfied	Are you satisfied with the clinical function of your device? Satisfied	Are you satisfied with the clinical function of your device? Very Satisfied	Are you satisfied with the clinical function of your device? N/A
Have we met your expectations/goals?	Have we met your expectations/goals? Dissatisfied	Have we met your expectations/goals? Slightly Satisfied	Have we met your expectations/goals? Satisfied	Have we met your expectations/goals? Very Satisfied	Have we met your expectations/goals? N/A

8. Your Overall Satisfaction With:

	Dissatisfied	Slightly Satisfied	Satisfied	Very Satisfied	N/A
Our practice?	*Your Overall Satisfaction With: Our practice? Dissatisfied	Our practice? Slightly Satisfied	Our practice? Satisfied	Our practice? Very Satisfied	Our practice? N/A
The quality of care you received at SCOPe?	The quality of care you received at SCOPe? Dissatisfied	The quality of care you received at SCOPe? Slightly Satisfied	The quality of care you received at SCOPe? Satisfied	The quality of care you received at SCOPe? Very Satisfied	The quality of care you received at SCOPe? N/A
Overall rating of care from your practitioner?	Overall rating of care from your practitioner? Dissatisfied	Overall rating of care from your practitioner? Slightly Satisfied	Overall rating of care from your practitioner? Satisfied	Overall rating of care from your practitioner? Very Satisfied	Overall rating of care from your practitioner? N/A

9. Would you recommend SCOPe to Others?

Would you recommend SCOPe to Others? Yes

If no, please tell us why:

10. Is there a way we can work to improve our services to you?

Is there a way we can work to improve our services to you?

11. Which office location were you seen?

Which office location were you seen?

12. Please supply the following information:

Please supply the following information: Name:
ZIP:
Email Address:
Phone Number:

13. How were you referred to SCOPe?

How were you referred to SCOPe? Doctor:
Friend:
Other:

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