Name:
Group:
Zip/Postal Code:
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Email:
Background:
How would you characterize your practice? (
please check all that apply)
Family Practice
General Practice
Internal Medicine
Pediatrics
Other:
How many physicians are in your practice?
Do you have a preferred orthopedic provider?
Why did you refer your patient to OSA?
Service:
Please rate the following on a scale of 1 (poor) to 5 (excellent):
1
2
3
4
5
Quality of treatment my patients received from OSA.
1
2
3
4
5
Quality of service I received from OSA.
1
2
3
4
5
OSA office staff was competent.
1
2
3
4
5
OSA office staff was friendly.
1
2
3
4
5
Were we accessible to your patients?
1
2
3
4
5
Referral process.
1
2
3
4
5
Feedback was delivered promptly.
1
2
3
4
5
Feedback was clear.
How can OSA serve you and your patients more effectively?
Where does OSA need to improve?
What other suggestions do you have for OSA?
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