Your Details

Name (Optional)

Date

Procedure

Pre Admission

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 than an Hour More than an Hour

If there was a long delay, was a reason given or did you arrive early?

Medical

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 the visit

Nursing Care

Were the nursing staff attentive? Yes No

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 given something to help it? Yes No

If so, was it prompt? Yes No

And if so, was it adequate? Yes No

Do you have any comments on the nursing care?

General Comfort

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 service to you?