The Intimate Image Catalog

	INTIMATE IMAGE - Patient Satisfaction Survey Your email: (optional) Your name: (optional) 1. How would you rate your overall experience with Intimate Image? Excellent Good Moderately good Moderately poor Poor Terrible 2. From the time of your first appointment at Intimate Image how long did it take before you received your items? Same day 1 to 2 days later 3 to 4 days later 5 to 7 days later More than 1 week later 3. Did you and your fitter discuss your plans and thoughts on how you will use your items as you go about your daily activities? Yes No 4. How would you rate the training you, or the person who takes care of you, received from Intimate Image regarding the items you recently received? Excellent Very good Good Fair Poor I didn't get any training 5. Have you had any major problems with the item(s)? Yes No 6. Have you contacted Intimate Image with a complaint or problem? Yes No 7. To whom did you address your complaint? 8. What was the nature of your complaint? 9. On what date did you register a complaint? 10. Was your complaint or problem settled to your satisfaction? Yes No I am waiting for it to be settled Not Applicable 11. Do you continue to use this/these items on a ongoing basis? Yes No 12. If you do not continue to use this/these items, is this due to a problem with the item(s)? Yes No 13. Did your physician order a different type of item/article? Yes No 14. Would you recommend Intimate Image to a friend? Yes No
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