Yes No Did your surgery begin as scheduled?
Yes No If there was a delay, did this create a problem for you and/or your family?
Yes No Were you pleased with your anesthesia care?
Yes No If your child had surgery, as a parent, do you feel that both of your needs were met?
Yes No Were your personal and informational needs met by the nursing staff?
Yes No Were you satisfied with the way your financial and insurance arrangements were handled?
Yes No If you or your family needs to have surgery again, would you return?
If you answered no to any of the above questions, please explain:
Please Rate Accordingly:
How would you rate the overall quality of your preparation/information given by the nursing staff?
5 - Outstanding 4 - Very Good 3 - Good 1 - Poor 2 - Fair
How would you rate your overall surgery experience at The Surgery Center?
What was MOST helpful about your visit to The Surgery Center?
Did you experience any complications post – operatively?
Was there anyone at The Surgery Center who made your visit more pleasant.
If so, please specify.
Date of Surgery:
Name:
Type of Surgery:
May We Contact you: Yes No
E-Mail*:
