Referral Survey First Name * Last Name * Phone Email * City & state: It is our desire to strive for excellence. In an effort to help us maintain our high standards, please take a few moments to tell us how we are doing. Please complete this form and note the response that most closely matches your experience. In thinking about your most recent experience with OrthoCare Medical Equipment LLC, how would you rate the quality of service you received as? 5 - Very Satisfied • 4 - Somewhat Satisfied • 3 - Neither Satisfied Nor Dissatisfied • 2 - Somewhat Dissatisfied • 1 - Very Dissatisfied Communication with our office: 54321 Professionalism of OrthoCare staff: 54321 Ease of making a referral / order: 54321 Availability of our staff to see your patients in our office: 54321 Timliness of equipment delivery to patient in clinic / hospital: 54321 Quality of equipment we carry: 54321 Variety of equipment we carry: 54321 Availability of equipment we carry: 54321 Knowledge of our staff regarding application and use of equipment: 54321 Patient education on application & use of equipment: 54321 Communication with patients regarding insurance coverage / billing: 54321 Helpfulness of our staff in meeting your DME needs: 54321 Timeliness / efficiency in resolving any patient complaints: 54321 What can we do to better serve you and your patients?
603 668 6688 
603 668 6688
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