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* 1. Please indicate the service you were seen for:

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* 2. Rate your overall experience?

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* 3. Would you recommend our department to your family and friends?

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* 4. Did you have any difficulties scheduling your appointment?

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* 5. Once you registered for your scheduled appointment your wait time to be seen in clinic was?

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* 6. During your visit how often did staff treat you with courtesy and respect?

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* 7. During your visit how often did staff listen carefully to you?

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* 8. During your visit how often did staff explain things in a way you could understand?

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* 9. The cleanliness and comfort of the department was:

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* 10. During your visit how often did staff maintain your privacy?

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* 11. For Procedure Patients only: Were your pre-procedure instructions clear and provide the necessary information?

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* 12. For Procedure Patients only: Were your post-procedure instructions clear and provide the necessary information?

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* 13. If you utilized services in other departments for this visit, please rate your experience:

  Excellent Very Good Good Fair Poor N/A
Admitting/Registration
Laboratory
Radiology
Cardiopulmonary

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* 14. Other comments:

Please take an Everyone Shines Here comment card to acknowledge
a staff member who deserves recognition.

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* 15. Date of visit (optional)

Date

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* 16. Contact information (optional)

Thank you for taking the time to fill out our survey so that we may improve our services to our patients. Your suggestions are very important to us.

If you have additional information or concerns please feel free to contact:

Outpatient Director

816-629-3524

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