Patient Satisfaction Survey
Rate the following on a scale of 1-5: 1=disagree, 3=neutral, 5=agree
Were the instructions you received prior to surgery helpful? *
Were your financial responsibilities discussed and your questions answered? *
Was the waiting time prior to surgery as expected and reasonable? *
Was the facility clean and well kept? *
Was the staff courteous and friendly? *
Was your privacy respected at all times? *
Was your pain level as expected and well controlled? *
Was adequate time allowed for your recovery? *
Were your homecare instructions clear and helpful? *
Did you feel safe at the facility? *
Overall, do you feel you received quality healthcare at the facilities? *
Date of Service *
MM
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DD
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YYYY
Clinic of Service *
Comments
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Patient Initials *
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