Patient Name:
Date of Service:
OST Staff Worked With:
Please rate your experience. Your answers help us improve care and meet Medicare quality standards.
Scale:
1 (Strongly Disagree) |2 (Disagree) |3 (Neutral) |4 (Agree) |5 (Strongly Agree)
I received clear instructions on how to use my brace:
12345
I was told how long and how often to wear the brace:
A staff member demonstrated proper use:
I received written instructions to take home:
I understand how to clean and maintain my brace:
I was treated with dignity and respect:
My privacy was protected:
I was involved in decisions about my care:
My rights as a patient were explained:
I understand my financial responsibility:
YesNo
I was told how to request adjustments or repairs:
It is easy to contact the provider for help:
Follow-up services were offered:
Overall satisfaction:
Likelihood to recommend:
Additional Comments:
