Survey / Forms - Northern Prosthetics & Orthopedic Inc.

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Patient Registration

Patient History

Release of Information

Medicare DMEPOS Supplier Standards

Patient Satisfaction Survey

Please take the time to answer the questions below and feel free to add your own comments.

Patient Satisfaction Survey

1) Were you able to obtain an appointment time that was convenient to you?

Yes

N/A

2) Was the receptionist friendly, professional and helpful?

Yes

N/A

3) Were you satisfied with the cleanliness of the waiting area, exam rooms and restrooms?

Yes

N/A

4) If you asked about our/your financial policy, were you sufficiently informed?

Yes

N/A

5) Were you seen in a timely manner?

Yes

N/A

6) Was the practitioner friendly and professional?

Yes

N/A

7) Did the practitioner explain what you need and why?

Yes

N/A

8) Were you given verbal or written instructions on use and care?

Yes

N/A

9) Did the practitioner spend a sufficient amount of time with you to answer all of your questions?

Yes

N/A

10) Was your device/equipment delivered in a timely manner?

Yes

N/A

11) Was a follow up appointment scheduled if needed?

Yes

N/A

12) Overall, were you satisfied with your experience at Northern Prosthetics and Orthopedic, Inc?

Yes

N/A

Practitioner

Would you like a member of Management to contact you?

Yes

N/A

if Yes, Phone:

Please provide any other comments or thoughts which will help us serve you better:

Signature (Optional):

Northern Prosthetics & Orthopedic Inc.
2629 Charles Street
Rockford, IL 61108
815-226-0444
Fax: 815-226-1819
info@northernpo.com
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Business Hours
M, T: 8 a.m.-5:00 p.m.
W, T, F: 8 a.m.-4:30 p.m.
Sat 8:30 a.m. to 12 p.m.