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 knowledgable My visit was quick and easy I received customer service All of the above
Who helped you at your visit? *

Jake Kinghorn Ben McKinley Kent Hamilton Alicia Berggren Melissa Stanton Jon Keene
Would you recommend Mountain Brace Systems to a friend? *

Yes No
Is there anything we could improve on?
Any final comments?
Optional: Contact Details
Your Name

First Name Last Name
E-mail
Phone Number

Area Code Phone Number
Should be Empty:

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