Patient Satisfaction Form Were you treated in a courteous, friendly, and professional manner by our administrative staff? Yes No Were you treated in a courteous, friendly, and professional manner by our practitioner? Yes No Did your practitioner meet with you in a prompt and timely manner? Yes No Did your practitioner spend enough time with you? Yes No Were the offices and treatment areas clean and comfortable? Yes No Did your practitioner explain matters clearly and completely, and take sufficient time to answer all of your questions? Yes No Did you receive detailed and understandable instructions on how to use, clean, and care for your device? Yes No Did you find your practitioner knowledgeable and skillful? Yes No Were you shown how to correctly put on and take off your prosthetic or orthotic device? Yes No Did you receive your device within a reasonable period of time after your initial fitting? Yes No Are you pleased with the comfort, quality, function, and fit of your device? Yes No Were you encouraged by your practitioner to immediately contact us if you have any problems or complications with your device? Yes No Did the staff discuss our billing and payment policy during your first visit? Yes No Did our staff discuss the product warranty with you? Yes No Were you satisfied overall with the practice? Yes No

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