Forms

Dear Patient

Among things considered when choosing a prosthetist, customer testimonials have always ranked very high. At Ropp Orthopedic Clinic we are proud to have you as a patient and we would love to know why you chose us and why you continue coming back. We would greatly appreciate your testimonial so we can help more amputees take “The next step forward”.

Since we would like to be able to use your recommendation to spread the word about what we do here at Ropp Orthopedic Clinic, please sign your name below to authorize us to use your testimonial in marketing materials for Ropp Orthopedic Clinic.

Name:_______________________________ Signature:_________________________________

If you would like the information used, but not put your name on it please check the box here O

Please return your questionnaire in the enclosed envelope. Those returned it by May 28^th, will be entered in a Ropp Orthopedic drawing for special gifts. Prizes are a one year membership in the Amputee Coalition of America ACA, and a Ropp Orthopedic prosthetic limb bag. (Only one prize per patient possible). In the meantime, enjoy this flashlight keychain courtesy of Ropp Orthopedic Clinic.

If you would like to download this digitally go to roppclinic.com/forms and chose Word or pdf format. You may email it back at roppclinic@aol.com or Jeff@roppclinic.com, or fax or mail it to us. Originally we thought it was possible to fill-out the forms on our website, but, because of HIPPA rules, found it easiest to email or mail.

Also if you have any prosthetic needs or problems be sure to call us for an appointment. We are now caring for diabetic patients with orthotic inserts and diabetic shoes as well with a Certified Pedorthist on staff, Mr. Ronald Ruzinsky.

Thank you in advance from your friendly team at Ropp Orthopedic Clinic.

Jeffrey Ropp, C.P, President

Michael Grace, Business Manager

Ronald Ruzinsky, C.Ped, Pedorthic Manager

The following questions might be helpful describing your experience with Ropp Orthopedic Clinic.

1. What is your overall impression about Ropp Orthopedic Clinic?
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2. Describe in detail a pleasant experience you have had with Jeff.
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3. Describe the one or two benefits from our products or services that you value most.
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4. Explain specifically how these benefits have enriched you in your daily life and work.

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Please circle the appropriate number from 1-worst (least) to 5-best (most)

Improved my quality of life 1 2 3 4 5

Able to walk better 1 2 3 4 5

Enjoyed the service of Ropp Orthopedics 1 2 3 4 5

Value of Ropp Orthopedics in my life 1 2 3 4 5

Comfort of my last prosthesis by Ropp Orthopedics 1 2 3 4 5

Friendliness of Staff of Ropp Orthopedic Clinic 1 2 3 4 5

If you would like to share any stories you have had with your prosthesis we would love to hear them as well. Please include this with your information.

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Ropp Orthopedic Clinic

The Next Step Forward