Customer Feedback Form
Do you have a compliment or concern?
What type of compliment are you providing?
Skill of the Clinician
What type of concern are you providing?
Skill of Staff
Device or Treatment
Who was the clinician you would like to compliment?
Are you the patient or an individual representing the patient:
Representative representing the patient
First Name (Representative):
Last Name (Representative):
Patient's First Name:
Patient's Last Name:
Patient's Primary Insurance:
Patient's Date of Birth:
Patient's Street Address 1:
Patient's Street Address 2:
Patient's Zip Code:
Date of Service:
Hanger Clinic location the compliment or concern is regarding:
(Please add street, city, state of location)
What service/product was provided to you when visiting the Hanger Clinic location?: