(815)717-8970

8:30 am - 5:00 pm Monday- Friday
After Hours Available By Appointment

(815)717-8970

1890 Silver Cross Blvd. #445 New Lenox IL 60451

info@rinella-op.com

8:30 am - 5:00 pm Monday- Friday

After hours available every weekday / weekends by appointment

After Hours Available By Appointment

24/7/365 on call

Patient Care. Dedication. Quality.

Home / Patient Satisfaction Survey

Patient Satisfaction Survey

Your response to this evaluation form is extremely important to us. Its purpose is to help us monitor the quality of our patient care. Your answers to these questions will be kept strictly confidential. If you have any additional comments, please provide those at the bottom of the form.

Date

Patient Name (optional)

Sex
 Male Female

Age

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

 Above Knee Prosthesis (AK) AFO Below Knee Prosthesis (BK) Compression Stocking Fracture Brace/Boot Hip Brace KAFO Knee/Elbow Immobilizer Neck Brace

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 Scoliosis Brace Shoe Insert Shoes SMO Soft Back Brace (corset) Soft Wrist/Hand Brace TLSO/LSO (Post-op back brace) UCB Upper Extremity Prosthesis

1. How long after calling for an appointment were you scheduled to be seen?
 Immediately Less than one week More than one week More than two weeks

2. Were you seen within 15 minutes of your scheduled time?
 Yes No

3. In your opinion, was the staff friendly & polite at all times?
 Yes No

4. When calling the office how long were you placed on hold?
 0-30 seconds 30 seconds-1 min 1-2 min more than 2 min

5. How well were the financial aspects of your care explained to you?
 Very well Somewhat well Not well

6. Was the prescribed device received in the time communicated to you?
 Yes No

7. At time of delivery, was the fit and function of the finished device:
 Excellent Satisfactory Unsatisfactory

8. Did the device need to be remade?
 Yes No

9. The workmanship & appearance of the finished device is:
 Excellent Satisfactory Unsatisfactory

10. In your opinion, did the practitioner possess the necessary skills to provide you with the required device?
 Yes No Unsure

11. Did you receive specific instructions from the practitioner?
 Yes No

12. Were you scheduled for a follow-up appointment at time of delivery?

13. Were patient waiting and treatments areas well-maintained?
 Yes No

14. Would you use these services again?
 Yes No

15. Are the office hours convenient?
 Yes No

16. Would you recommend these services to others?
 Yes No

17. How would you rate the value of the service(s) delivered to you?
 Very valuable Somewhat valuable Not valuable

Any additional comments/observations? Please provide comments below:


Please leave this field empty.

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