Guarantor Name:
*
Patient Name:
*
Address:
*
Phone:
*
Email:
*

1: When you called for an appointment; Were appointments available to see a practitioner within 10 working days?
Yes No

2: On your first appointment; Were your insurance benefits along with our billing & payment policies discussed with you?
Yes No

3: When you came into our office; Did you see a practitioner within 15 minutes?
Yes No

4: Did the practitioner explain brace application, warranty and repairs with you?
Yes No

5: Did you receive educational material about your brace and your practitioners business card?
Yes No

6: Were you asked to schedule a follow-up appointment?
Yes No

7: Did the office staff ask you to take our online survey which is located on our website?
Yes No

8: Are you satisfied with your brace?
Yes No

9: Are you satisfied with our service and patient care?
Yes No

10: Would you refer a family member or friend to us?
Yes No

Please place a check beside of the practitioner that you see:*
Barry Fowler, Sr.
Barry Fowler, Jr.
Bob Thomas

Thank you for any feedback or comments:

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