Your Name (required)

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Date of Service (required)

Are you satisfied with the device?
 Yes No

Were your goals of treatment realistically formulated and achieved?
 Yes No

Did our staff treat you courteously during your visits?
 Yes No

Were you given enough time with your practitioner?
 Yes No

Were your questions answered satisfactorily?
 Yes No

Did you receive sufficient information on how to best use your device?
 Yes No

How would you rate the quality of the service you received?
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Is your device a good fit?
 Yes No

Is your device comfortable?
 Yes No

Do you like the looks/design of your device?
 Yes No

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