Patient Satisfaction Survey

Thank you for completing this questionnaire. Your feedback is very important to us.

Survey Code:

Please rate your agreement with the following statements:

Date of Service: mm/dd/yyyy

Registration
Helpfulness of the person at the registration desk	Very Poor Poor Good Very Good N/A
Ease of registration process	Very Poor Poor Good Very Good N/A
Waiting time in registration area	Very Poor Poor Good Very Good N/A
Facility
Comfort of waiting area	Very Poor Poor Good Very Good N/A
Cleanliness of facility	Very Poor Poor Good Very Good N/A
Our Nursing Care
Friendliess/courtesy of staff who provided treatment	Very Poor Poor Good Very Good N/A
Skill of the staff who provided treatment	Very Poor Poor Good Very Good N/A
Staff's concern for comfort	Very Poor Poor Good Very Good N/A
Staff's concern for your questions and worries	Very Poor Poor Good Very Good N/A
Personal Issues
Our concern for your privacy	Very Poor Poor Good Very Good N/A
Our sensitivity to your needs	Very Poor Poor Good Very Good N/A
Response to concerns/complaints during your visit	Very Poor Poor Good Very Good N/A
Our Anesthesia Staff
The anesthesiologist was courteous and friendly	Very Poor Poor Good Very Good N/A
The anesthesiologist spent time reviewing my anesthesia care and answering my questions	Very Poor Poor Good Very Good N/A
Your Surgeon
My surgeon was courteous and friendly	Very Poor Poor Good Very Good N/A
My surgeon spent time explaining my procedure and answering my questions	Very Poor Poor Good Very Good N/A
My Recovery
My pain level was as expected and well controlled	Very Poor Poor Good Very Good N/A
Adequate time was allowed for my recovery	Very Poor Poor Good Very Good N/A
My homecare instructions were clean and helpful	Very Poor Poor Good Very Good N/A
Home Follow-Up
When I was contacted at home, the clinical staff was concerned for my progress and comfort and answered my questions	Very Poor Poor Good Very Good N/A
Overall Assessment
Overall rating of care received during visit	Very Poor Poor Good Very Good N/A
Likelihood of your recommending our facility to others	Very Poor Poor Good Very Good N/A

Any comments or suggestions? (Describe good or bad experience)

Would you like to be contacted to discuss any concerns? Yes No
If you have any medical questions or concerns, please contact your surgeon.

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