1. Were you treated in a courteous, friendly, and professional fashion by our administrative staff?
   
               Yes      No
   
2. Did your practitioner meet with you in a prompt and timely manner?
   
               Yes      No
   
3. Were the offices and treatment areas clean and comfortable?
   
               Yes      No
   
4. Did your practitioner explain matters clearly and completely, and take
   sufficient time to answer all of your questions?
   
               Yes      No
   
5. Did you receive detailed and understandable instructions on how to use,
   clean, and care for your device?
   
               Yes      No
   
6. Were you shown how to correctly don your prosthetic or orthotic device?
   
               Yes      No
   
7. Did you receive your device within a reasonable period of time after your
   initial fitting?
   
               Yes      No
   
8. Are you pleased with the comfort, functionality, quality and fit of your device?
   
               Yes      No
   
9. Were you encouraged by your practitioner to immediately contact us if you
   have any problems or complications with your device?
   
               Yes      No
   
10.   Did our staff discuss billing and payment options during your first visit?
    
                Yes      No

If you feel there is any way we can improve our service
and make future visits more comfortable, please let us know:

Patient Name (optional)

First	Last	MI		M	/D	/Y
email:

Facility Visited

All information is for internal use only.
It will Only be used by PrimeCare quality assurance personnel!