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.

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

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

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

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

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6. I have found that my orthosis / prothesis is adequate for my needs.

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7. The appearance and workmanship of my orthosis / prothesis is to my satisfaction.

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8. the Orthotist / Prosthetist who provided my service, was knowledgable and skillful.

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9. Overall, I was satisfied with the quality of treatment I received.

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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?