SATISFACTION SURVEY

We appreciate you having your procedure with us, and we want to make sure we met your expectations. Please let us know how satisfied you were in the following areas.

SCORING:

1 = Excellent
2 = Very Good
3 = Good
4 = Fair
5 = Poor

Overall
How satisfied are you with your experience at this center overall?

How satisfied are you with your experience at this center overall? 1 2 3 4 5
Registration-Check in:
Staff courtesy & efficiency

Staff courtesy & efficiency 1 2 3 4 5
Answers to your questions

Answers to your questions 1 2 3 4 5
Before procedure/surgery:
Maintenance of privacy

Maintenance of privacy 1 2 3 4 5
Concern for your well being

Concern for your well being 1 2 3 4 5
Length of waiting time

Length of waiting time 1 2 3 4 5
Anesthesia:
Treated with courtesy

Treated with courtesy 1 2 3 4 5 N/A
Did the anesthesia provider speak to you before procedure?

Did the anesthesia provider speak to you before procedure? Yes No N/A
Did you have the opportunity to ask questions?

Did you have the opportunity to ask questions? Yes No N/A
After procedure:
Concern for your well being

Concern for your well being 1 2 3 4 5 N/A
Answers to your questions

Answers to your questions 1 2 3 4 5 N/A
Attention from your doctor

Attention from your doctor 1 2 3 4 5 N/A
Maintenance of your privacy

Maintenance of your privacy 1 2 3 4 5 N/A
Family kept informed

Family kept informed 1 2 3 4 5 N/A
Pain control adequate

Pain control adequate 1 2 3 4 5 N/A
Departure:
Staff's courtesy and efficiency

Staff's courtesy and efficiency 1 2 3 4 5 N/A
Clarity of discharge instructions

Clarity of discharge instructions 1 2 3 4 5 N/A
Explanation of where to call if problems arose

Explanation of where to call if problems arose 1 2 3 4 5 N/A
Readiness to leave after recovery

Readiness to leave after recovery 1 2 3 4 5 N/A
When you went home, did you experience any of the following:
Recovery went as expected

Recovery went as expected Yes No
Fever above 101 degrees?

Fever above 101 degrees? Yes No
Abnormal bleeding or draining?

Abnormal bleeding or draining? Yes No
Vomiting more than 24 hours?

Vomiting more than 24 hours? Yes No
Pain not controlled by medication?

Pain not controlled by medication? Yes No N/A
Did any of these specific problems cause you to:
Call your doctor?

Call your doctor? Yes No
Visit your doctor?

Visit your doctor? Yes No
Visit the emergency room?

Visit the emergency room? Yes No
Return to our center?

Return to our center? Yes No
YOUR HEALTH CARE CHOICE
Who made the decision for you to come to this center for your procedure? (Check all that apply)

Who made the decision for you to come to this center for your procedure? (Check all that apply) My choice Center accepted my insurance Physician's direction No choice Other: If other, please describe Other: If other, please describe
If you decided, what influenced your decision to have your procedure done at this center? (Check all that apply)

If you decided, what influenced your decision to have your procedure done at this center? (Check all that apply) Cost Return home same day Location of facility Recommendation by friend/physician No choice Other: If other, please describe Other: If other, please describe
How likely would you be to return to our center if you needed a procedure again?

How likely would you be to return to our center if you needed a procedure again? Definitely would Probably would Indifferent Probably would not Definitely would not Other: If other, please describe Other: If other, please describe
Demographics
Sex:

Sex: Male Female
Age:

Age: 0-15 16-25 26-35 36-45 46-55 56-65 Over 65
Zip Code:
Procedure date: Procedure date: / MM / DD YYYY
Today's date: Today's date: / MM / DD YYYY
Name of doctor:
Insurance Company:
Name: (Optional)
Phone #: (Optional)
Email Address:
Comments:
Do we have your permission to share your comments on our website?
(If yes, be sure to leave your comments in the Comment Box above)

Do we have your permission to share your comments on our website?
(If yes, be sure to leave your comments in the Comment Box above) Yes No

SATISFACTION SURVEY

SATISFACTION SURVEY

Overall

Registration-Check in:

Before procedure/surgery:

Anesthesia:

After procedure:

Departure:

When you went home, did you experience any of the following:

Did any of these specific problems cause you to:

YOUR HEALTH CARE CHOICE

Demographics