Asheville Eye Surgery Center (AESC) Patient Satisfaction Survey

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* 1. Date of Service

Date

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* 2. Please select your surgeon:

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* 3. PLEASE RESPOND TO THE FOLLOWING QUESTIONS

	GREAT	GOOD	OK	FAIR	POOR
Ease of scheduling your surgery	Ease of scheduling your surgery GREAT	Ease of scheduling your surgery GOOD	Ease of scheduling your surgery OK	Ease of scheduling your surgery FAIR	Ease of scheduling your surgery POOR
Quality and efficiency of check-in process	Quality and efficiency of check-in process GREAT	Quality and efficiency of check-in process GOOD	Quality and efficiency of check-in process OK	Quality and efficiency of check-in process FAIR	Quality and efficiency of check-in process POOR
Courtesy and care of your physician	Courtesy and care of your physician GREAT	Courtesy and care of your physician GOOD	Courtesy and care of your physician OK	Courtesy and care of your physician FAIR	Courtesy and care of your physician POOR
Satisfaction with your anesthesia care provider	Satisfaction with your anesthesia care provider GREAT	Satisfaction with your anesthesia care provider GOOD	Satisfaction with your anesthesia care provider OK	Satisfaction with your anesthesia care provider FAIR	Satisfaction with your anesthesia care provider POOR
Courtesy and care of nursing staff	Courtesy and care of nursing staff GREAT	Courtesy and care of nursing staff GOOD	Courtesy and care of nursing staff OK	Courtesy and care of nursing staff FAIR	Courtesy and care of nursing staff POOR
Clear instructions were given for post-operative care	Clear instructions were given for post-operative care GREAT	Clear instructions were given for post-operative care GOOD	Clear instructions were given for post-operative care OK	Clear instructions were given for post-operative care FAIR	Clear instructions were given for post-operative care POOR
Comfort and cleanliness of our surgery center	Comfort and cleanliness of our surgery center GREAT	Comfort and cleanliness of our surgery center GOOD	Comfort and cleanliness of our surgery center OK	Comfort and cleanliness of our surgery center FAIR	Comfort and cleanliness of our surgery center POOR
Confidence in your overall surgical experience	Confidence in your overall surgical experience GREAT	Confidence in your overall surgical experience GOOD	Confidence in your overall surgical experience OK	Confidence in your overall surgical experience FAIR	Confidence in your overall surgical experience POOR

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* 4. Financial obligations were communicated clearly

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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* 5. Clear instructions were given for pre and postoperative care

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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* 6. Additional comments regarding your surgery day:

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* 7. How likely are you to recommend our Surgery Center to a colleague, friend or family member?

Not at all likely

Neutral

Extremely Likely

Not at all likely

Neutral

Extremely Likely

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* 8. I hereby grant permission for AESC to use my comments for marketing and/or online

Yes