Surgery Patient Satisfaction Survey

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1. Please enter:

	MM		DD		YYYY
Date of Surgery	Please enter: Date of Surgery Month	/	Day	/	Year

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2. Which ophthalmic category best describes the nature of your recent surgery at EMG?

Which ophthalmic category best describes the nature of your recent surgery at EMG? Glaucoma Cataract	Retina Ocular Plastic Surgery
Other (please specify)

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3. Questionnaire Completed By:

Questionnaire Completed By:

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4. Please select the physician your visit was with

Please select the physician your visit was with

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5. Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area.

How satisfied were you with:

	NOT Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied	N/A
the information received from your physician’s office to prepare you for surgery?	*Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area. How satisfied were you with: the information received from your physician’s office to prepare you for surgery? NOT Satisfied	the information received from your physician’s office to prepare you for surgery? Somewhat Satisfied	the information received from your physician’s office to prepare you for surgery? Satisfied	the information received from your physician’s office to prepare you for surgery? Very Satisfied	the information received from your physician’s office to prepare you for surgery? N/A
the post-op instructions provided to you on your day of surgery?	the post-op instructions provided to you on your day of surgery? NOT Satisfied	the post-op instructions provided to you on your day of surgery? Somewhat Satisfied	the post-op instructions provided to you on your day of surgery? Satisfied	the post-op instructions provided to you on your day of surgery? Very Satisfied	the post-op instructions provided to you on your day of surgery? N/A
the answers to your questions regarding anesthesia?	the answers to your questions regarding anesthesia? NOT Satisfied	the answers to your questions regarding anesthesia? Somewhat Satisfied	the answers to your questions regarding anesthesia? Satisfied	the answers to your questions regarding anesthesia? Very Satisfied	the answers to your questions regarding anesthesia? N/A
pain management, if you did experience eye pain?	pain management, if you did experience eye pain? NOT Satisfied	pain management, if you did experience eye pain? Somewhat Satisfied	pain management, if you did experience eye pain? Satisfied	pain management, if you did experience eye pain? Very Satisfied	pain management, if you did experience eye pain? N/A
(please check N/A if you did not experience pain)	(please check N/A if you did not experience pain) NOT Satisfied	(please check N/A if you did not experience pain) Somewhat Satisfied	(please check N/A if you did not experience pain) Satisfied	(please check N/A if you did not experience pain) Very Satisfied	(please check N/A if you did not experience pain) N/A
the quality of nursing care?	the quality of nursing care? NOT Satisfied	the quality of nursing care? Somewhat Satisfied	the quality of nursing care? Satisfied	the quality of nursing care? Very Satisfied	the quality of nursing care? N/A
the overall care you experienced?	the overall care you experienced? NOT Satisfied	the overall care you experienced? Somewhat Satisfied	the overall care you experienced? Satisfied	the overall care you experienced? Very Satisfied	the overall care you experienced? N/A
the courtesy, professionalism and efficiency of staff?	the courtesy, professionalism and efficiency of staff? NOT Satisfied	the courtesy, professionalism and efficiency of staff? Somewhat Satisfied	the courtesy, professionalism and efficiency of staff? Satisfied	the courtesy, professionalism and efficiency of staff? Very Satisfied	the courtesy, professionalism and efficiency of staff? N/A
the follow-up call you received from a staff member after surgery?	the follow-up call you received from a staff member after surgery? NOT Satisfied	the follow-up call you received from a staff member after surgery? Somewhat Satisfied	the follow-up call you received from a staff member after surgery? Satisfied	the follow-up call you received from a staff member after surgery? Very Satisfied	the follow-up call you received from a staff member after surgery? N/A
the cleanliness of the Surgery Center?	the cleanliness of the Surgery Center? NOT Satisfied	the cleanliness of the Surgery Center? Somewhat Satisfied	the cleanliness of the Surgery Center? Satisfied	the cleanliness of the Surgery Center? Very Satisfied	the cleanliness of the Surgery Center? N/A

6. What did you like most about the Surgery Center?

What did you like most about the Surgery Center?

7. What did you like least about the Surgery Center?

What did you like least about the Surgery Center?

8. Other Comments:

Other Comments:

9. Your Name (Optional)

Your Name (Optional)

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Surgery Patient Satisfaction Survey

*1. Please enter:

*2. Which ophthalmic category best describes the nature of your recent surgery at EMG?

*3. Questionnaire Completed By:

*4. Please select the physician your visit was with

*5. Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area.How satisfied were you with: