Patient Survey 1) The information and instructions given to me before my procedure were:ExcellentVery GoodGoodFairPoor 2) At check-in, registration staff answered my questions about billing and insurance information:ExcellentVery GoodGoodFairPoor 3) The level of personal interest and care I received from my Anesthesiologist was:ExcellentVery GoodGoodFairPoor 4) The courtesy and professionalism of your nursing staff toward me and my family member/care giver was:ExcellentVery GoodGoodFairPoor 5) The Level of personal interest and care I received from my Doctor was:ExcellentVery GoodGoodFairPoor 6) The protection of confidentiality and my personal privacy was:ExcellentVery GoodGoodFairPoor 7) The cleanliness and comfort of your facility was:ExcellentVery GoodGoodFairPoor 8) The management of pain after my procedure was:ExcellentVery GoodGoodFairPoor 9) The Instructions given to me upon discharge were:ExcellentVery GoodGoodFairPoor 10) My overall experience and the care I received at your facility was:ExcellentVery GoodGoodFairPoor 11) Did you experience any unexpected problems after your procedure?YesNo If YES, please explain: 12) What did you like most about our facility? 13) What did you like least about our facility? 14) Would you recommend our facility to your family and friends?Definitely YesProbably YesProbably NoDefinitely No 15) Please list any other comments or suggestions that you might have: 16) Please list any employees who provided you with exceptional service: Procedure Type:SurgicalColonoscopy/EndoscopyPain ManagementOther Date of Procedure: Name (Optional): Doctor's Name (Optional):
