Patient Survey

It was our pleasure to serve you! Please let us know about your experience at our facility.

Questions with "*" at the end of the message are required!

Procedure Type: *	Surgical	Colonoscopy/Endoscopy	Pain Management	Other
Date of Procedure: *
Name (Optional):
Doctor's Name (Optional):

	Excellent	Very Good	Good	Fair	Poor
1. The information and instructions given to me by the Nurse during the PreOp phone call were: *
2. At check-in, the ability of the staff to answer my questions was: *
3. The level of personal interest and care I received from my Anesthesiologist was: *
4. The courtesy and professionalism of the nursing staff toward me and my family member/caregiver was: *
5. The Level of personal interest and care I received from my Doctor was: *
6. The protection of confidentiality and my personal privacy was: *
7. The cleanliness and comfort of the facility was: *
8. The management of pain after my procedure was: *
9. The instructions given to me upon discharge were: *
10. My overall experience and the care I received at your facility was: *

	Yes	No
11. Did you experience any unexpected problems after your procedure? *
11.1. If yes, please explain:

12. What did you like most about our facility? *
13. What do you feel could have been improved upon at our facility? *

	Definitely Yes	Probably Yes	Probably Not	Definitely Not
14. Would you recommend our facility to your family and friends? *

15. Please list any other comments or suggestions you might have: *
16. Please list any employees that provided you with exceptional service: *