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Anonymous Patient Survey

Dear Patient:
Please rate our performance by checking the response that best describes your evaluation. Feel free to add comments. Thank you for your input and feedback.

Survey English

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ADMITTING/REGISTRATION

1. Professional and courteous office staff

Excellent

Good

Poor

Very Poor

2. Speed and efficiency of registration

Excellent

Good

Poor

Very Poor

3. Satisfactory answers to financial and insurance questions

Excellent

Good

Poor

Very Poor

NURSING

4. Professional and courteous service of nurses

Excellent

Good

Poor

Very Poor

5. Nurses introducing themselves and keeping you informed

Excellent

Good

Poor

Very Poor

6. Nurses explaining procedures

Excellent

Good

Poor

Very Poor

7. Satisfactory answers to questions

Excellent

Good

Poor

Very Poor

8. Written instructions for your home care

Excellent

Good

Poor

Very Poor

OVERALL

9. Staff giving you the privacy you needed

Excellent

Good

Poor

Very Poor

10. Cleanliness and comfort of the Surgery Center

Excellent

Good

Poor

Very Poor

11. Likelihood that you will return or recommend the Surgery Center to others

Excellent

Good

Poor

Very Poor

12. OVERALL, rating your experience at the Surgery Center

Excellent

Good

Poor

Very Poor

Additional comments

OPTIONAL INFORMATION

Name

Email