* 1. Please enter:

Date of Surgery

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

* 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?
the post-op instructions provided to you on your day of surgery?
the answers to your questions regarding anesthesia?
pain management, if you did experience eye pain?
(please check N/A if you did not experience pain)
the quality of nursing care?
the overall care you experienced?
the courtesy, professionalism and efficiency of staff?
the follow-up call you received from a staff member after surgery?
the cleanliness of the Surgery Center?

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

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

* 8. Other Comments:

* 9. Your Name (Optional)