Patient Satisfaction Survey

1. Information and instructions given to you before your procedure

ExcellentVery GoodGoodFairPoor

2. Registration staff explanations about billing and insurance information.

ExcellentVery GoodGoodFairPoor

3. Information given to you regarding the potential risks/complications of the type of anesthesia you received.

ExcellentVery GoodGoodFairPoor

4. Courtesy and professionalism of nursing staff toward you and your family member/caregiver.

ExcellentVery GoodGoodFairPoor

5. Protection of confidentiality and personal privacy.

ExcellentVery GoodGoodFairPoor

6. Degree to which your pain was controlled while at our center.

ExcellentVery GoodGoodFairPoor

7. Instructions given to you upon discharge.

ExcellentVery GoodGoodFairPoor

8. Cleanliness and comfort of the facility.

ExcellentVery GoodGoodFairPoor

9. Response to concerns/complaints, if any, during your visit.

ExcellentVery GoodGoodFairPoor

10. Your overall experience and the care you received at our facility.

ExcellentVery GoodGoodFairPoor

11. Did you experience any unexpected problems after your procedure?

YesNo

If yes, please explain:

12. What did you like most about the facility?

13. What did you like least about the facility?

14. Would you recommend this facility to your family and friends?

Definitely YesProbably NotProbably YesDefinitely Not

15. Please list any general comments, suggestions, or employee who provided exceptional service.

Type of procedure:

SurgicalPain ManagementOther (please provide the details in the space provided:

Date of Procedure:

Name (optional):

Doctors name (optional):