Here at Michigan Hand & Sports Rehab Centers our primary goal is providing the best possible care to our patients. Still, we are always looking for ways to improve our service. Please take the time to fill out the survey below so that we can continue to provide you with the first class care you have come to expect.

Patient:
Initial Visit:
Reffering Doctor:
Orthosis Type:	prefabricated custom made
Beyond the initial fitting how many adjustments were necessary:

Was your appointment scheduled within a reasonable amount of time?
Yes	No	N/A
Were you seen within 15 minutes of your scheduled time?
Yes	No	N/A
Was the patient waiting and treatment area well maintained?
Yes	No	N/A
Was your orthosis fitted within a timely manner?
Yes	No	N/A
Did the front office staff answer all of your questions concerning billing and payment responsibilities?
Yes	No	N/A
Would you and your family recommend our services to other patients?
Yes	No
Please rate the following questions. Did the Orthotist:
Treat you with courtesy?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Explain donning, doffing and wearing of your orthosis?:
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Explain how to care for your orthosis?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Involve you in setting your goals?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Explain the goals/purpose and function of your orthosis?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Respect your privacy?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Instruct you how to contact our office if you have any problems?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Please rate the fit, function, workmanship and appearance of your orthosis?
Excellent (5)	Very Good (4)	Good (3)	Fair (2)	Poor (1)
Additional Comments: