====================== Patient Satisfaction Survey ======================

Your opinion means a great deal to us. We care what you think. We want your experience
to be the best it can. We think that means the friendliest, most responsive staff
providing personal, professional service.

But what do you think ? Please take a few minutes of your time and let us know what you
liked (or didn't like) about our services. Any comments would be appreciated.
Thank you for your assistance.


Date of Surgery: (mm/dd/yy)

Patient Name:

1. Was the waiting time reasonable for your procedure        Yes   No  

2. Were the forms you signed explained to you          Yes   No  

3. Did you feel you were cared for efficiently and competently        Yes   No  

4. Did your surgeon speak with you or a family member following the surgery        Yes   No  

5. Were your questions answered by the nursing staff prior to the procedure        Yes   No  

6. Were signs and symptons of possible problems that may occur at home explained to you        Yes   No  

7. If problems occurred at home, did you know whom to call        Yes   No  

8. Did you understand how to take care of yourself at home        Yes   No  

9. Was your privacy provided for and respected        Yes   No  

10. Did you feel you were treated with respect and courtesy at all times        Yes   No  

11. Was financial responsibility for your procedure made clear        Yes   No  

12. Did you feel safe before, during and after your surgery (if no, please comment below)        Yes   No