East Coast Orthotic & Prosthetic Corp.

Quality Assurance Survey
Required Required Question(s)
1.

If you called for your appointment were you given the option of an appointment within 24 hours of your call?
Yes
No
N/A
2.

Were you seen within 15 minutes of your scheduled appointment?
Yes
No
N/A
3.

Was the person who greeted you courteous?
Yes
No
4.

Was the practitioner who fit the device on you knowledgeable?
Yes
No
5.

Did he/she explain the care and use of the device that you received?
Yes
No
6.

Did he/she address any issues you had with the device to your satisfaction?
Yes
No
7.

Are you satisfied with the clinical function of the device?
Yes
No
8.

Would you recommend East Coast to a friend or family member?
Yes
No
9.

Additional comments:
 

  • 350 characters left.
Required 10.

Patient Name:
 

  • 50 characters left.
Required 11.

Date:
 

  • 50 characters left.
Required 12.

May we contact you to discuss your experience with East Coast?
Yes
No
13.

Phone Number: (555-555-5555)
 

  • 50 characters left.
14.

Email address: (abc123@mail.com)
 

  • 50 characters left.
Required 15.

Service Location:
 

  • 50 characters left.
Required 16.

Practitioner:
 

  • 50 characters left.