Survey Form Physician Date Were you treated in a courteous, pleasant and professional manner? By the business office staff? YesNo By the nursing staff? YesNo On the telephone? YesNo Was your procedure fully explained to you by your physician? YesNo Did your pre-op call or your admission nurse inform you of what to expect during your visit? YesNo Did you receive adequate information about your financial responsibilities? YesNo Were the lighting, temperature and general surroundings comfortable to you? YesNo Was the separation from your family/friends explained to you? YesNo Were written instructions given to you and reviewed with you and/or Caregiver before leaving the facility? YesNo If given the choice, would you choose to come to this facility again? YesNo If not, why? How would you rate your overall experience? ExcellentGoodFairPoor How could we have improved your experience the day of the surgery? Please list two suggestions for how we can improve? Would you like someone to contact you? If so, please provide us with your name and contact phone number: Your Email (required) Thank you in advance for your cooperation
