Customer Satisfaction Survey

Customer Satisfaction Survey

Please fill out the following based on your visit

The brace/orthotics/equipment was provided in a timely manner*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

Your medical history was reviewed by the fitter*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

The staff answered your questions in easy to understand terms*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

Your insurance carrier was billed promptly*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

Your follow-up care, fitting, and/or questions were resolved quickly*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

What is your opinion of our overall performance*

	1	2	3	4	5

1 is Unsatisfactory, 5 is Excellent

What was the best part of your visit?*

My fitter was knowledgableMy visit was quick and easyI received customer serviceAll of the aboveOther
Who helped you at your visit?*

Jake KinghornBen McKinleyKent HamiltonAlicia BerggrenMelissa StantonJon KeeneOther
Would you recommend Mountain Brace Systems to a friend?*

YesNo
Is there anything we could improve on?
Any final comments?
Optional: Contact Details
Your Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Should be Empty: