Name of medical institution*
Profile of medical institution
Contact person and position*
Tel/fax*
E-mail*
1. Have you had problems using our devices? YesNo
2. Are you satisfied with the time of delivery? Choose from 1 to 5, where 1 – absolutely unsatisfied; 5 – absolutely satisfied. 12345
3. Are you satisfied with the quality of our devices? Choose from 1 to 5, where 1 – absolutely unsatisfied; 5 – absolutely satisfied. 12345
4. Estimate the convenience of work with our devices, choose from 1 to 5, where 1 – absolutely inconvenient; 5 – absolutely convenient. If your answer is less than 5 – leave comments. 12345
5. Estimate the effectiveness of our devices? choose from 1 to 5, where 1 – treatment is ineffective and/or associated with big difficulties; 5 – absolutely effective, no problems detected. If your answer is less than 5 – provide comments. 12345
6. Based on the patients’ feedback estimate treatment with the use of our devices? choose from 1 to 5, where 1 – very unpleasant; 5 – causes no discomfort. If your answer is less than 5 – provide comments. 12345
Leave your additional comments on the above questions or other issues.
What other factors shall be considered by the manufacturer? Write your recommendations, remarks
