Please rate the quality of the information and instructions given to you. 1. Prior to Surgery Excellent Good Fair Poor Please Choose 2. Regarding Anesthesia: Risks/complications/choices: Excellent Good Fair Poor Please Choose 3. Prior to discharge (home care): Excellent Good Fair Poor Please Choose Please rate the level of courtesy and professionalism displayed by the staff: 4. Admissions/Billing Excellent Good Fair Poor Please Choose 5. Pre-Op (Before Surgery) Excellent Good Fair Poor Please Choose 6. O.R. Staff (During Surgery) Excellent Good Fair Poor Please Choose 7. Post-Op (After Surgery) Excellent Good Fair Poor Please Choose 8. Please rate the level of care and personal interest you received from your physician. Excellent Good Fair Poor Please Choose 9. Please rate how your pain was managed. Excellent Good Fair Poor Please Choose 10. Please rate the cleanliness and comfort of the facility. Excellent Good Fair Poor Please Choose 11. Please rate the protection of your privacy. Excellent Good Fair Poor Please Choose 12. Please rate the treatment and courtesy given to your family member/caregiver. Excellent Good Fair Poor Please Choose 13. Please rate the convenience of having your procedure performed at our facility. Excellent Good Fair Poor Please Choose 14. Please rate your overall experience and the care you received. Excellent Good Fair Poor Please Choose 15. Were you notified of your surgery time within 48 hrs? Yes No Please Choose 16. Why did you choose our facility? Physician Insurance Cost Other 17. Please let us know any comments or suggestions you have. What did you like most/least about the facility? Date of procedure: Name (optional): Surgeon’s name: May we contact you about your comments/concerns? Yes No Please Choose
Please rate the quality of the information and instructions given to you.
17. Please let us know any comments or suggestions you have. What did you like most/least about the facility?
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