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The Compliance Team
Exemplary Provider Satisfaction Measure© — Orthopedic (Non-Clinical) Survey
Requested By: Edward Arabov at Healthy Corner Pharmcy
Your Name:
First:      Last:
Your Phone #:
New or Existing Patient:   
Equipment Category:
Model or Serial # (as applicable):
Date Of Service:  (mm/dd/yyyy format)
Delivery and Instruction Tech Name:

 Access, Delivery and ServiceYesNoN/A
1Was the device set-up in a timely manner?
2Did you have pain at any level before the device was set-up?
3Were the proper instructions given at time of application?
4Did the device fit comfortably?
5Instructions given on use/application of device?
6Did the representative review billing policies?
7Do you feel confident to operate/use/apply the device?
8Were you satisfied with the service/recommend to others?

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