Patient Satisfaction Survey Your Opinion counts! Patient Name (required) Patient Email (required) Patient Age (required) Type of device worn (required) PLEASE RATE US ON A SCALE OF 1-5 WITH 5 INDICATING EXCELLENT AND 1 POOR SELECT THE NUMBER YOU FEEL MOST APPROPRIATE 1. My appointment was scheduled in a reasonable amount of time and the person whom I spoke with was courteous and helpful. ---12345 2. I was seen within 15 minutes of my appointment and if not, the reason for the delay was explained to me. ---12345 3. I found the waiting and treatment areas clean and well maintained. ---12345 4. The services provided to me were delivered in a reasonable amount of time. ---12345 5. Considering its limitations. I found the fit and function of my orthotics / prosthesis satisfactory. ---12345 6. I have found that my orthosis / prothesis is adequate for my needs. ---12345 7. The appearance and workmanship of my orthosis / prothesis is to my satisfaction. ---12345 8. the Orthotist / Prosthetist who provided my service, was knowledgable and skillful. ---12345 9. Overall, I was satisfied with the quality of treatment I received. ---12345 10. I received specific recommendations and/or instructions on proper care and use of my orthosis / prothesis. ---YesNo 11. I would recommend Pro-Fit to others requiring such services. ---YesNo 12. Would you like to speak to someone about the services provided? ---YesNo What do you feel needs to be improved? Would you like to provide a Testimonial?