Patient Type Orthotic Prosthetic

Date of Visit

Location Visited Select Location Chicago - Western Ave. Brookfield Chicago - Peterson Ave. Arlington Heights Joliet Naperville Merrillville, IN

Practitioner Select Practitioner Mark Devens John Adamski Rachel Raub Shenan Hoppe-Ludwig Pawel Brzozka

Please tell us about your experience at your last visit.  For questions that ask for ratings of 1 to 5, 1 is Poor, 3 is Average and 5 is Excellent.

Overall Experience Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Courteous / Helpful Staff Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Confidence in Skill of Practitioner Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Treated with Care and Compassion Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Did you have adequate understanding of your device? Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Cleanliness and Comfort of Facility Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

Ease of Finding Location Select Your Rating 1 - Poor 2 3 - Average 4 5 - Excellent

How many miles did you travel?

Would you return to MD LABS for services? Yes No

Are you wearing your device? Yes No

If yes, how often?

Do you feel the device is helping you? Yes No Somewhat

Please use the space below to provide us with any additional feedback.

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