1. Was your appointment scheduled promptly when you called?
Yes
No
If No, Please Explain
2. Was your scheduled appointment on time?
Yes
No
If No, Please Explain
3. Were billing matters handled to your expectations?
Yes
No
If No, Please Explain
4. What kind of device were you fitted with?
5. Do you feel the orthotist/prosthetist spent an adequate
amount of time with you?
Yes
No
If No, Please Explain
6. Did the orthotist/prosthetist explain the proper way to apply
and remove your orthotic/prosthetic appliance?
Yes
No
If No, Please Explain
7. Were you provided with adequate follow-up care?
Yes
No
If No, Please Explain
8. Was the office staff helpful and courteous?
Yes
No
If No, Please Explain
9. Are you satisfied with the outcome of your care?
Yes
No
If No, Please Explain
10. Does your orthotic/prosthetic meet your expectations?
Yes
No
If No, Please Explain
11. Would you recommend our facility to someone you know?
Yes
No
If No, Please Explain
Signature ____________________(optional) Date (MM/DD/YY) ________
Patient Satisfaction Survey
Suburban Orthotics &
Prosthetics Inc
