Wolverine Orthotics: Patient Evaluation Form

Patient Service Evaluation Form

You have been fit with an orthosis (brace) from our office and your satisfaction with our service is important to us. Please take a few minutes to complete the questionnaire so we may continue to provide outstanding care for YOU!

Patient Name (optional):
Patient Email (optional):
Date of Visit to Wolverine:
Primary Practitioner:
Type of Orthosis:

On a scale from 1 to 5, where 1 represents Very Dissatisfied* and 5 represents Very Satisfied, please rate the following 1-9 questions below:*
1. You found our office easy to locate?		1 2 3 4 5
2. The waiting area was comfortable?		1 2 3 4 5
3. Your wait time was a reasonable amount of time?		1 2 3 4 5
4. Office staff was courteous to you?		1 2 3 4 5
5. The office staff was able to answer your insurance questions promptly?		1 2 3 4 5
6. The Orthotist/practitioner thoroughly explained the wearing instructions for your brace?		1 2 3 4 5
7. You were educated about your condition and the brace(s)?		1 2 3 4 5
8. You left Wolverine Orthotics, Inc. feeling you could contact the office if you had questions and/or concerns?		1 2 3 4 5
9. How satisfied are you with the success of the device you were fitted with?		1 2 3 4 5

10. Did you have a scheduled appointment?		Yes No Walk-in
11. How did you hear about Wolverine Orthotics, Inc.?
Additional Comments:
Thank you for your time!

Wolverine Orthotics, Inc.
28455 Haggerty Road, Suite 101 | Novi, MI 48377
Phone: (248) 324-3010 | Fax: (248) 324-3003