The Compliance Team

Patient Satisfaction Survey — Orthopedic (Non-Clinical)

Items below designated with an asterisk ( *) are required.
Requested By:	Edward Arabov at
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?
2	Did you have pain at any level before the device was set-up?
3	Were the proper instructions given at time of application?
4	Did the device fit comfortably?
5	Instructions given on use/application of device?
6	Did the representative review billing policies?
7	Do you feel confident to operate/use/apply the device?
8	Were you satisfied with the service/recommend to others?

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.