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Customer Feedback Form
Do you have a compliment or concern?
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Compliment
Concern
What type of compliment are you providing?
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Device Usefulness
Skill of the Clinician
Staff Demeanor
Other
What type of concern are you providing?
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CRO
DM Shoes and Inserts
Lower Limb Orthotics
Lower Limb Prosthetics
Mastectomy
Other
Shoes & Inserts
Spinal
Upper Limb Orthotics
Upper Limb Prosthetics
WalkAide
Scoli
Who was the clinician you would like to compliment?
Were there casts, scans, impressions, and/or detailed measurements taken?
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Yes
No
Unsure
Are you the patient or an individual representing the patient:
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Patient
Representative representing the patient
First Name (Representative):
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Last Name (Representative):
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Patient's First Name:
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Patient's Last Name:
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Patient's Primary Insurance:
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Patient's Date of Birth:
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Patient's Street Address 1:
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Patient's Street Address 2:
Patient's City:
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Patient's State:
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Patient's Zip Code:
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Email Address:
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Phone Number:
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Date of Service:
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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?:
Message:
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