Patient Satisfaction Survey

Our goal at Prosthetic Laboratories is to provide you with the highest quality orthotic and prosthetic services. To do this, we need to know your thoughts about the care you are receiving. We welcome and value your comments and assure you that your feedback will be kept strictly confidential.

Some of our questions are based on a scale of 1 to 5 with the highest number (5) being the most positive response (for example: 5=Excellent, 3=Average, 1=Very Poor). Please select the number that reflects your response.

When you have completed the survey, please click on the Submit Survey button. Your responses will be sent electronically to our main office. You will also be given the option to print a copy of your completed survey. If you would like to send your responses by mail, please use the following address: Prosthetic Laboratories, Confidential Patient Satisfaction Survey, 121 23rd Ave SW, Rochester, MN 55902.

Date:

Office Location:

What type of service did you receive? (Select all that apply)

Neck brace
Hip brace
Fracture brace/boot
Soft back brace (corset) Knee/elbow immobilizer
TLSO/LSO
(Post-op back brace)

AFO
KAFO
SMO
Below knee prosthesis (BK)
Above knee prosthesis (AK)
Upper extremity
Prosthesis

Shoe insert
Compression stocking
UCB
Soft wrist/hand brace
Shoes
Scoliosis brace
Mastectomy supplies

Who referred you to Prosthetic Laboratories?

a. Are you a new or previous patient?
b. Were you seen for a new orthosis/prosthesis or a repair/adjustment

Did you have a scheduled appointment? Yes No

If you telephoned, the person who answered your call was:
(Courteous) 5 4 3 2 1 (Discourteous)

After you arrived, the practitioner saw you within minutes.

Do you feel that you were attended to in a timely manner?
Yes No

How were you treated by our staff during your visit?
Receptionist: 5 4 3 2 1
Practitioner: 5 4 3 2 1
(Pleasantly) (Impersonally)

Were you satisfied with the amount of time your practitioner spent with you?
(Very satisfied) 5 4 3 2 1 (Dissatisfied)

The practitioner’s instructions and explanations of your orthotic/prosthetic device and care were:
(Excellent) 5 4 3 2 1 (Inadequate)

10.

The practitioner was:
(Concerned) 5 4 3 2 1 (Indifferent)

11.

Was the device completed when promised?
Yes No

12.

Do you have any questions or concerns that were not addressed?
Yes No

13.

If yes, do you wish to be personally contacted about any questions or concerns? Yes No

If yes, please provide your:	Name
	Telephone Number

14.

The fees for your service were paid for by:
You
Private Insurance
Medicare
HMO/PPO
Other

15.

Were you satisfied with the billing process for your services?
(Very satisfied) 5 4 3 2 1 (Dissatisfied)

16.

How can we improve our services?

17.

Was the physical environment clean and pleasant?
Lobby              Yes No
Patient Room    Yes No
Other               Yes No

18.

Were you satisfied with the services rendered? Yes No