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Patient Satisfaction Survey — Orthopedic (Non-Clinical)
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:
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
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