Toll Free: 866.914.AOPS
Prosthetic Fabrication Satisfaction Survey
PATIENT INFORMATION:
* = Required
Today's Date:
Patient's Name:
*
Patient Invoice# :
Your Name:
Device Type:
SURVEY QUESTIONS:
Did you receive the product on time?
Yes
No
Did you receive all the supplies requested?
Yes
No
Please grade your overall satisfaction with the product:
A
B
C
D
F
Please grade your level of satisfaction with each of the following:
Lamination
A
B
C
D
F
Alignment
A
B
C
D
F
Set Up
A
B
C
D
F
Trim/Buff
A
B
C
D
F
Cosmesis
A
B
C
D
F
Product Cost
A
B
C
D
F
If you contacted us:
Did you get a timely response?
Yes
No
Did you feel the people you spoke to, to be knowledgeable?
Yes
No
Was our staff pleasant to deal with?
Yes
No
Do You have any additional Comments?
