Aljan Company - Orthotics Patient Survey FRONT OFFICE * Before and during your appointment, were you: Treated respectfully on the phone? Strongly Disagree Disagree Neutral Agree Strongly Agree Addressed in a pleasant and professional manner? Strongly Disagree Disagree Neutral Agree Strongly Agree Asked beforehand to bring your insurance cards and prescriptions? Strongly Disagree Disagree Neutral Agree Strongly Agree BILLING * Before and during your DELIVERY appointment, were you: Informed of your out of pocket/copay amount? Strongly Disagree Disagree Neutral Agree Strongly Agree Able to understand assignment of your Medicare? Strongly Disagree Disagree Neutral Agree Strongly Agree Provided with adequate answers for your billing questions? Strongly Disagree Disagree Neutral Agree Strongly Agree PRACTITIONER * Before and during your appointment, were you: Explained the use, care, and maintenance of your device? Strongly Disagree Disagree Neutral Agree Strongly Agree Able to find footwear appropriate for your device? Strongly Disagree Disagree Neutral Agree Strongly Agree Advised on how to put on / take off your device properly? Strongly Disagree Disagree Neutral Agree Strongly Agree Included in the decisions regarding your treatment? Strongly Disagree Disagree Neutral Agree Strongly Agree Able to comfortably ask your practitioner questions? Strongly Disagree Disagree Neutral Agree Strongly Agree OVERALL * I felt my privacy was respected Strongly Disagree Disagree Neutral Agree Strongly Agree My device has improved my quality of life. Strongly Disagree Disagree Neutral Agree Strongly Agree Considering its limitations, I am satisfied with overall fit/function. Strongly Disagree Disagree Neutral Agree Strongly Agree My device was delivered within the time frame we discussed. Strongly Disagree Disagree Neutral Agree Strongly Agree I would refer to a friend or family member to the Aljan Company Strongly Disagree Disagree Neutral Agree Strongly Agree I would like someone to contact me regarding the services I received * Yes No My practitioner was: * Joe Blake Megan Kaelee Molly Name (optional) First Name Last Name Email (optional) Phone (optional) (###) ### #### Please provide any comments, thoughts, or opinions that would help us better serve you. Thank you!
