PATIENT SATISFACTION SURVEY

NAME:    (Optional)
TYPE OF DEVICE:	Orthotic Prosthetic
PRACTITIONER:   (Optional)	--Select One-- Allison Bressler Ann Lawall Bo Powers Brooke Keiper Bruce Goodman Christopher Lawall Christopher Michalowski Christopher Robbins Cindy Groff Darin Oskison Dave Marshall David Lawall Doug Davis Ed Miller Ed Moran Frank Colucciello Frank Williamson Gary Michalowski George Henderson George Kirby George Miller Greg Skowronski Harry Lawall, Sr. Harry Lawall, Jr. Jack Lawall Jeff Hirsch Jeff Koach Jeff Shaw Joe Hagen John Condo John Stills Linda Bennett Lisa Hewitt Matt Moran Mike Fischer Mike Godwin Mike Hagen Mike Hamer Mike Kelly Patrick Frank Pete Michener Rich Bash Rob Sheely Robert Nadler Ron Lewis Ruben Barraza Stephen Campbell Steve Schneider Steven Chu Steve Schneider Wayne Lawall
OFFICE WHERE YOU WERE SEEN:	--Select One-- N.E. Philadelphia S.W. Philadelphia Willow Grove, PA Sellersville, PA Yardley, PA Wyomissing, PA Lawrenceville, NJ Vineland, NJ Cape May Court House, NJ Cherry HillL, NJ Toms River, NJ Springfield, PA Hershey, PA Shriners Hospital-Philadelphia A.I. duPont Hospital-Wilmington, DE Augustine Cut-Off - Wilmington, DE Dover, DE Other (hospital, nursing home, etc.

Please respond to the following questions:
Was your appointment scheduled within a reasonable amount of time?	Yes No
Were you seen within 15 minutes of your scheduled appointment time?	Yes No
Were the waiting and treatment areas well maintained and comfortable?	Yes No
Was the receptionist courteous and professional?	Yes No
Were your financial responsibilites explained in a professional manner?	Yes No
Was your device completed on the day promised to you?	Yes No
How many fittings were needed?	--Select One-- One Two Three or More
Would you describe the fit and comfort of your device as:	--Select One-- Excellent Satisfactory Unsatisfactory
At delivery, were major changes needed to the device?	Yes No
Did the device need to be remade?	Yes No
The quality of workmanship and appearance of the completed device is:	--Select One-- Excellent Satisfactory Unsatisfactory
Were you treated professionally by the Orthotist or Proshtetist?	Yes No
Were you given written instructions on the care and use of your device?	Yes No
What was your overall experience at Lawall's?	--Select One-- Excellent Good Fair Poor
Addtional Comments: