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We want to be sure that we offer you the highest level of service and medical care. Help us by completing this brief, confidential survey below.

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* 1. Patient name (Optional)

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* 2. Which provider(s) did you see today?

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* 3. Before you arrived, were you given a clear explanation of any instructions that you needed to follow before having your examination?

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* 4. Did you have a long wait before the procedure?

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* 5. Was the area clean?

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* 6. Was the staff polite?

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* 7. Was your procedure clearly explained?

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* 8. After your procedure, did you receive clear instructions about any directions you needed to follow after going home?

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* 9. Did you feel you were provided with appropriate privacy?

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* 10. How would you rate your anesthesia experience with us?

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* 11. Would you return to our office again if you needed medical services?

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* 12. How would you rate your overall experience with us?

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* 13. Additional comments or questions?

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