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.

—Please choose an option—12345

2. I was seen within 15 minutes of my appointment and if not, the reason for the delay was explained to me.

—Please choose an option—12345

3. I found the waiting and treatment areas clean and well maintained.

—Please choose an option—12345

4. The services provided to me were delivered in a reasonable amount of time.

—Please choose an option—12345

5. Considering its limitations. I found the fit and function of my orthotics / prosthesis satisfactory.

—Please choose an option—12345

6. I have found that my orthosis / prothesis is adequate for my needs.
—Please choose an option—12345

7. The appearance and workmanship of my orthosis / prothesis is to my satisfaction.
—Please choose an option—12345

8. the Orthotist / Prosthetist who provided my service, was knowledgable and skillful.
—Please choose an option—12345

9. Overall, I was satisfied with the quality of treatment I received.
—Please choose an option—12345

10. I received specific recommendations and/or instructions on proper care and use of my orthosis / prothesis.
—Please choose an option—YesNo

11. I would recommend Pro-Fit to others requiring such services.
—Please choose an option—YesNo

12. Would you like to speak to someone about the services provided?
—Please choose an option—YesNo

What do you feel needs to be improved?

Would you like to provide a Testimonial?