Satisfaction Survey
Patient Name *
Facility Name *
Type of Service *
Required
Name of Person Completing Form *
Title of Person Completing Form *
Is the Patient satisfied with the product(s) and its (their) function? *
Did the product(s) operate properly at the time of delivery? *
Was the product(s) delivered at the agreed upon time? *
Were adequate instructions provided on the safe use of the product(s)? *
How would you rate the overall product provided to your patient? *
Least Desirable
Most Desirable
How would you rate the interaction between the practitioner and the patient? *
Least Desirable
Most Desirable
How would you rate the interaction between the practitioner and yourself? *
Least Desirable
Most Desirable
How would you rate the promptness of the practitioner for the scheduled appointment? *
Least Desirable
Most Desirable
How likely would you be to recommend Orthocare America, Inc. to others? *
Least Desirable
Most Desirable
Please list any further comments that you would like to share with our company
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy