Orthotic Prosthetic Solutions, LLC

Satisfaction Survey

OPS strives to provide quality service and devices to all of our patients. Recently you were fit with a brace, prosthesis, foot inserts, shoes, compression stockings, or mastectomy supplies by one of our practitioners. OPS values your opinion and will use this information to address areas that may need improvement. Please take a few minutes of your time to complete the survey and thank you for your time.

Patient's Name:

Date of Service:

Practitioner Providing Your Care:

I was sent to or heard about OPS from:

When completing the following questions, please select the number that best describes your experience.
1 – Strongly Disagree	4- Somewhat Agree
2- Somewhat Disagree	5- Strongly Agree
3- Neutral	NA – Not Applicable

INITIAL TELEPHONE CONTACT AND SCHEDULING

I was greeted in a friendly manner:
1 2 3 4 5 NA

I was given an appointment at a convenient time:
1 2 3 4 5 NA

I understood where and when the appointment was:
1 2 3 4 5 NA

RECEPTION AT TIME OF APPOINTMENT

I was greeted in a friendly manner:
1 2 3 4 5 NA

My questions were answered to my satisfaction:
1 2 3 4 5 NA

I was informed of my Privacy Rights:
1 2 3 4 5 NA

I understood the forms:
1 2 3 4 5 NA

The forms were easy to fill out:
1 2 3 4 5 NA

The Warranty and Return Policy were easy to understand:
1 2 3 4 5 NA

INSURANCE AND BILLING INFORMATION

My benefits were explained to me:
1 2 3 4 5 NA

I understood my financial responsibility:
1 2 3 4 5 NA

I was treated with respect:
1 2 3 4 5 NA

PRACTITIONER CARE

I was seen at my appointed time:
Yes No NA

The practitioner explained what was being prescribed for me:
1 2 3 4 5 NA

I received the device in a timely manner:
1 2 3 4 5 NA

The practitioner explained how to put on and take off the device:
1 2 3 4 5 NA

The practitioner explained the break-in period:
1 2 3 4 5 NA

The practitioner explained how to care for my device:
1 2 3 4 5 NA

I felt the practitioner was listening to me:
1 2 3 4 5 NA

I felt the practitioner was knowledgeable about his/her profession:
1 2 3 4 5 NA

I felt the practitioner was taking his/her time and was not rushed:
1 2 3 4 5 NA

I felt the practitioner addressed my questions and concerns:
1 2 3 4 5 NA

I felt the practitioner made sure my device fit properly and was comfortable:
1 2 3 4 5 NA

QUALITY OF THE DEVICE

My device fits well and is comfortable:
1 2 3 4 5 NA

My device works well for my problem:
1 2 3 4 5 NA

How would you rate your overall experience with Orthotic Prosthetic Solutions?
[Poor ] 1 2 3 4 5 [Excellent ] Not Sure

ANY ADDITIONAL CONCERNS OR COMMENTS