PATIENT SATISFACTION SURVEY

Instructions: We would like to know how you feel about your experience at our Endoscopy Center. Please select one Response for each of the following questions:

1. The availability, helpfulness, sincerity of our endoscopy center staff by phone.
Excellent Very Good Good Fair Poor
2. The knowledge, helpfulness and attitude of our reception/registration staff
Excellent Very Good Good Fair Poor
3. Overall comfort, amenities, cleanliness and accessibility of our facility
Excellent Very Good Good Fair Poor
4. The experience in terms of how safe and secure you felt
Excellent Very Good Good Fair Poor
5. Your confidence in the skills of OUR nursing staff
Excellent Very Good Good Fair Poor
6. Doctor(s) ability and willingness to address questions about your care
Excellent Very Good Good Fair Poor
7. Your confidence in the skill of your physician
Excellent Very Good Good Fair Poor
8. Were you kept informed of any delays in your procedure start time
Excellent Very Good Good Fair Poor
9. Effectiveness in meeting your overall time expectations
Excellent Very Good Good Fair Poor
10. The clarity, explanation, and completeness of your discharge instructions
Excellent Very Good Good Fair Poor
11. The helpfulness of the Center in answering questions during your post-op call
Excellent Very Good Good Fair Poor
12. All Center staff worked as team, and respected your privacy and dignity
Excellent Very Good Good Fair Poor
13. Probability you will return to our facility for future endoscopic needs
Excellent Very Good Good Fair Poor
14. Would you like us to contact you about any of your answers to the survey?
No Yes
Enter Comments:
What kind of comment is it?
General Suggestion Complaint
Select the physician you had appointment with?
Butani Kang Kim Lai Mohan Murakami Rees Lui Selinger Tzung Winters Wohlman
Date Of Visit:
Patient Name (Optional):
Patient Phone (Optional):

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