Name (Optional)
Date
Procedure
Were the reception staff friendly and courteous? Yes No
How long did you have to wait before the procedure? Less than 1/2 Hour Less and an Hour
If there was a long delay, was a reason given or did you arrive early?
Did you receive a satisfactory explanation of the procedure? Yes No
Was the immediate outcome of the procedure and the followup explained by the surgeon? Yes No
Please comment on the medical aspects of your visit
Was pain relief/control required? Yes No
If so, was it prompt? Yes No
And if so, was it adequate? Yes No
Did you feel ill (nauseous) and were you given something to help it? Yes No
Please comment on the nursing care
Was the temperature of the rooms satisfactory? Yes No
Were the furnishings comfortable? Yes No
Do you have any suggestions that would help us improve our services to you?
