Patient Satisfaction Survey

PLEASE RATE THE FOLLOWING:

A. YOUR APPOINTMENT:

1. Ease of making appointments by phone
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. Appointment available within a reasonable amount of time
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. Greeted upon arrival
ExcellentVery GoodGoodFairPoorDoes Not Apply

4. Waiting time in the reception area
ExcellentVery GoodGoodFairPoorDoes Not Apply

5. Waiting time in the exam room
ExcellentVery GoodGoodFairPoorDoes Not Apply

6. Keeping you informed if your appointment time was delayed
ExcellentVery GoodGoodFairPoorDoes Not Apply

B. OUR STAFF:

1. The courtesy of the person who took your call
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. The friendliness and courtesy of the Certified Fitter
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. The caring concern of our Staff
ExcellentVery GoodGoodFairPoorDoes Not Apply

4. The helpfulness of the people who assisted you with billing or insurance
ExcellentVery GoodGoodFairPoorDoes Not Apply

5. The professionalism of our staff
ExcellentVery GoodGoodFairPoorDoes Not Apply

C. OUR COMMUNICATION WITH YOU:

1. Your phone calls answered promptly
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. Getting advice or help when needed during office hours
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. Explanation of the benefits of your items
ExcellentVery GoodGoodFairPoorDoes Not Apply

4. Effectiveness of our health information materials
ExcellentVery GoodGoodFairPoorDoes Not Apply

5. Our ability to return your calls in a timely manner
ExcellentVery GoodGoodFairPoorDoes Not Apply

D. YOUR VISIT WITH THE PROVIDER:

1. Willingness to listen carefully to you
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. Taking time to answer your questions
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. Amount of time spent with you
ExcellentVery GoodGoodFairPoorDoes Not Apply

4. Explaining things in a way you could understand
ExcellentVery GoodGoodFairPoorDoes Not Apply

5. Instructions regarding Bras and Prosthesis/follow-up care
ExcellentVery GoodGoodFairPoorDoes Not Apply

6. The thoroughness of the examination
ExcellentVery GoodGoodFairPoorDoes Not Apply

E. OUR FACILITY:

1. Hours of operation convenient for you
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. Overall comfort
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. Adequate parking
ExcellentVery GoodGoodFairPoorDoes Not Apply

4. Signage and directions easy to follow
ExcellentVery GoodGoodFairPoorDoes Not Apply

F. YOUR OVERALL SATISFACTION WITH:

1. Our practice
ExcellentVery GoodGoodFairPoorDoes Not Apply

2. The quality of your medical care
ExcellentVery GoodGoodFairPoorDoes Not Apply

3. Overall rating of care
ExcellentVery GoodGoodFairPoorDoes Not Apply

WOULD YOU RECOMMEND THE PROVIDER TO OTHERS?
YesNo

IF NO, PLEASE TELL US WHY:

IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

SOME INFORMATION ABOUT YOU:

GENDER
MaleFemale

YOUR AGE
Under 1818-3031-4041-5051-60Over 60

ARE YOU:
A new patientA returning patient

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