700 South Claremont Street, Suite 105, San Mateo, CA 94402

Phone: (650) 375-2231 Fax: (650) 627-4632

PATIENT SATISFACTION SURVEY

To assist us in improving our services, please complete this Patient Satisfaction Survey with reference to the device/service provided to you at Align Clinic. Please mail or fax your responses back to us at your earliest convenience.

  1. Were you treated in a friendly and courteous manner by our staff? ___ Yes ___ No
  2. Were you able to schedule a convenient appointment? ___ Yes ___ No
  3. With respect to your scheduled appointment time, please mark your impression:

___ I was seen on time or early ___ I was seen shortly after ___ I had to wait a long time

  1. If you did not have a scheduled appointment, please describe your impression:

___ I had a very short wait time ___I had to wait a moderate amount, but not too bad

___ The wait was too long

  1. How comfortable was the waiting area?

___ Very ___ OK ___ Needs improvement

  1. Did the staff inform you of your financial responsibility? ___ Yes ___ No
  2. How would you rate the knowledge, care, and attention that the practitioner provided to you during your visit?

___ Excellent ___ Good ___ Satisfactory ___ Needs improvement

  1. Was your device received within the time frame promised? ___ Yes ___ No
  2. How useful were the instructions regarding the use, function, care, and precautions associated with your device?

___ Very useful ___ Somewhat useful ___ Somewhat confusing ___ I didn’t get instructions

  1. Do you use your device on a daily basis or some other frequency?

___ Daily ___ 3-5 times per week ___ less than 3 days a week ___ Not at all

  1. What is your opinion of the overall services provided by your practitioner?

___ Excellent ___ Satisfactory ___ Needs improvement

  1. Were your questions and concerns about your device answered to your satisfaction?

___ Yes ___ No

  1. Were your questions and concerns about your care answered to your satisfaction?

___ Yes ___ No

  1. How comfortable is your device?

___ I forgot I was wearing it! ___ It feels fine ___ It’s uncomfortable ___ It hurts

  1. Are you satisfied with your device? ___ Yes ___ No
  2. Were you instructed about whom to contact if a problem develops? ___ Yes ___ No
  3. Would you recommend us to others if they were in need of similar services?

___ Yes ___ No If no, why not?______

  1. Do you have any other comments or suggestions you would like to offer in reference to any of the questions above or otherwise? ______

Thank you for your participation. We appreciate your time and the opinions offered.

______

Patient Name Date