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Patient Survey

Please rate our performance by checking the response that best describes your evaluation. Fell dree to add comments. Upon completion, please submit form. Thank you for your input and feedback.

Please note a survey will be requested to be completed for each visit

Physician who performed procedure
Date of Service

ADMITTING/REGISTRATION

Professional and courteous service of office staff

Please select option below
Excellent
Good
Poor
Not Applicable

Speed and efficiency of registration

Please select option below
Excellent
Good
Poor
Not Applicable

Satisfactory answers to financial and insurance questions

Please select option below
Excellent
Good
Poor
Not Applicable

NURSING

Professional and courteous service of nurses

Please select option below
Excellent
Good
Poor
Not Applicable

Nurses introducing themselves and keeping you in formed

Please select option below
Excellent
Good
Poor
Not Applicable

Observe nurses wearing mask and PPE when required

Please select option below
Excellent
Good
Poor
Not Applicable

Satisfactory answers to questions regarding care expectations

Please select option below
Excellent
Good
Poor
Not Applicable

Written instructions for your home care

Please select option below
Excellent
Good
Poor
Not Applicable

ANESTHESIA STAFF/ SURGEON

How would you rate the anesthesia staff on explaining the anesthesia process and answering your questions?

Please select option below
Excellent
Good
Poor
Not Applicable

Did the anesthesia staff provide clear instructions about what to expect before, during, and after the procedure?

Please select option below
Excellent
Good
Poor
Not Applicable

Were your concerns or fears about anesthesia addressed satisfactorily?

Please select option below
Excellent
Good
Poor
Not Applicable

How would you rate the overall care provided by the anesthesia staff?

Please select option below
Excellent
Good
Poor
Not Applicable

Did the surgeon explain the procedure clearly and provide adequate time for your questions?

Please select option below
Excellent
Good
Poor
Not Applicable

Were you satisfied with the post-operative instructions and follow-up care information provided by the surgeon?

Please select option below
Excellent
Good
Poor
Not Applicable

How would you rate the surgeon’s attention to your concerns and needs?

Please select option below
Excellent
Good
Poor
Not Applicable

How would you rate the overall care provided by the surgeon?

Please select option below
Excellent
Good
Poor
Not Applicable

How well did the anesthesia staff and surgeon coordinate their care?

Please select option below
Excellent
Good
Poor
Not Applicable

Were you treated with respect and dignity by both the anesthesia staff and the surgeon?

Please select option below
Excellent
Good
Poor
Not Applicable

OVERALL

Staff giving you the privacy you needed

Please select option below
Excellent
Good
Poor
Not Applicable

Cleanliness and comfort of the surgery center

Please select option below
Excellent
Good
Poor
Not Applicable

Likelihood that you would return or recommend the Surgery Center

Please select option below
Excellent
Good
Poor
Not Applicable

OVERALL, rating of your experience at the Surgery Center?

Please select option below
Excellent
Good
Poor
Not Applicable
Are there any issues shared in the comment section above if applicable, that you need immediate attention and requires further discussion to resolve your issue?
Yes
No
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