Patient Survey Name First Last What type of device did you receive? Orthotic(s) Prosthetic(s) Pedorthics(s) Mastectomy Other Other How would you rate your appointment time and scheduling? Excellent Above Average Average Below Average Poor How would you rate your experience with, and knowledge of our insurance department staff? Excellent Above Average Average Below Average Poor CommentsDid our staff inform you of any expense that you may be liable for should your insurance company deny or reduce payment for services rendered to you? Yes No Did you agree to pay for any expenses you may incur if your insurance company denies or reduces payment of your claim? Yes No How would you rate the knowledge, care and attention that our Practitioner provided to you during your visit? Excellent Above Average Average Below Average Poor CommentsOverall, how would you rate your new device and does it meet your satisfaction? Excellent Above Average Average Below Average Poor CommentsWere you given verbal and/or written instructions on the use and care of your new device? Yes No Were you completely satisfied with the overall experience your encountered by our Practitioners and staff during your visit? Yes No CommentsWere you asked to call our office, or make another appointment for a follow up appointment if necessary? Yes No Is there anything else you'd like to share with us?