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Patient Satisfaction Survey — Orthopedic (Non-Clinical)
Items below designated with an asterisk (
*
) are required.
Requested By:
Your Name:
First:
Last:
Your Phone #:
Use the following format (XXX) XXX-XXXX
New or Existing Patient:
*
New
Existing
Equipment:
*
Make or Serial # (as applicable):
Date of Service:
*
(mm/dd/yyyy format)
Delivery and Instruction Tech Name:
Unknown
Access, Delivery and Service
Yes
No
N/A
1
Was the device set-up in a timely manner?
Reason:
Update Reason
2
Did you have pain at any level before the device was set-up?
Reason:
Update Reason
3
Were the proper instructions given at time of application?
Reason:
Update Reason
4
Did the device fit comfortably?
Reason:
Update Reason
5
Instructions given on use/application of device?
Reason:
Update Reason
6
Did the representative review billing policies?
Reason:
Update Reason
7
Do you feel confident to operate/use/apply the device?
Reason:
Update Reason
8
Were you satisfied with the service/recommend to others?
Reason:
Update Reason
COMMENTS:
We greatly appreciate your input. We use patient satisfaction survey reports to help us improve our day-to-day services. Please take an extra minute to provide details for your survey responses in the box below.
Question:
You answered, "No" for the question shown above. Using the text box below, please provide the details as to why you answered, "No".
Please provide your details in the text box above and then click the "Save" button below.
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