Patient Surgery Survey

Name *

Surgery Date

How did you hear about us? Please specify media: i.e., television, radio, print, billboard or other?

What were your motivating factors for choosing us?

What was your main concern prior to surgery?

What was it that alleviated this concern for you?

What improvements should be made related to informing you of expectations, before, during and after surgery?

On a scale of 1-10 (10 being the highest) please rate our reception staff on your day of surgery.

On a scale of 1-10 (10 being the highest) please rate our clinical staff on your day of surgery.

On a scale of 1-10 (10 being the highest) please rate our doctors on your day of surgery.

On a scale of 1-10 (10 being the highest) please rate your overall experience on your day of surgery.

Please feel free to comment further.

In what way(s) could your overall surgical experience have been improved?

Would you recommend our facility to others?

If no, why?

Would you be willing to speak to prospective patients regarding your experience?

If yes, please inform us of the best time of day and number you could be reached at.

Any additional comments to better serve our patients are welcomed.