Evaluation Form

Submitted by Administrator on Mon, 01/23/2012 - 13:03

We are pleased to have had you as a patient.

We would like to know about your experience, as our facilities strive to provide the highest quality medical care.

Patients’ responses are directly responsible for ensuring that we can meet your expectations and needs.

All responses will be kept Confidential and Anonymous. Thank you for your time and feedback.

1. What type of service did you receive from one of our clinics?

2. Over the phone, I was treated professionally and with care.

3. At the center, the registration staff was courteous, helpful and friendly.

4. The waiting room was clean and comfortable.

5. My questions were thoroughly answered.

6. The O.R. staff made me feel comfortable and at ease with my procedure.

7. The recovery room staff was friendly and responsive to my needs.

8. I was treated professionally by my doctor.

9. Efforts were made to keep my information private.

10. Overall, I am pleased with the care I received at the center.

12. What did you like best about our center?

13. Would you like a manager to contact you to discuss any concerns or questions?

14. Name

15. Phone Number (If you wish to be contacted)

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