Patient Satisfaction Survey Posted on November 24, 2015 * Name of Surgeon * Date of Surgery * How Would You Rate Your Experience? 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Receptionist/Front Desk Personnel 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Our Staff 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Anesthesia Personnel 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Your Doctor 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * The Answers to Your Questions – Information, Teaching, Instructions 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Your Companion’s Experience 1 = Unacceptable 2 = Poor 3 = Average 4 = Good 5 = Excellent * Was the waiting time for your surgery reasonable? make a selection…yesno * If necessary, would you choose to have surgery here again? make a selection…yesno * Would you refer your friends to Advanced Surgical Center Inc. ? make a selection…yesno
