Patient Satisfaction Survey

Please take a moment to provide us with feedback on your visit to The Orthopaedic Surgery Center.
Your input will be used to help us continually improve our services.

Please rate the quality of your interaction with the Surgery Center staff:

Question Title

* 1. Prior to your procedure:

	Excellent	Fair	Poor	N/A
Passport Online Registration	Passport Online Registration Excellent	Passport Online Registration Fair	Passport Online Registration Poor	Passport Online Registration N/A
Reception and Registration Process	Reception and Registration Process Excellent	Reception and Registration Process Fair	Reception and Registration Process Poor	Reception and Registration Process N/A

Other (please specify)

Question Title

* 2. During Your Procedure:

	Excellent	Fair	Poor	N/A
Interaction with pre-op staff	Interaction with pre-op staff Excellent	Interaction with pre-op staff Fair	Interaction with pre-op staff Poor	Interaction with pre-op staff N/A
Interaction with anesthesia staff	Interaction with anesthesia staff Excellent	Interaction with anesthesia staff Fair	Interaction with anesthesia staff Poor	Interaction with anesthesia staff N/A
Interaction with operating room staff	Interaction with operating room staff Excellent	Interaction with operating room staff Fair	Interaction with operating room staff Poor	Interaction with operating room staff N/A
Interaction with recovery staff	Interaction with recovery staff Excellent	Interaction with recovery staff Fair	Interaction with recovery staff Poor	Interaction with recovery staff N/A

Other (please specify)

Question Title

* 3. Please Rate The Following:

	Excellent	Fair	Poor	N/A
Please rate the quality of information and education you received from the Surgery Center staff regarding your procedure and how you would feel afterwards.	Please rate the quality of information and education you received from the Surgery Center staff regarding your procedure and how you would feel afterwards. Excellent	Please rate the quality of information and education you received from the Surgery Center staff regarding your procedure and how you would feel afterwards. Fair	Please rate the quality of information and education you received from the Surgery Center staff regarding your procedure and how you would feel afterwards. Poor	Please rate the quality of information and education you received from the Surgery Center staff regarding your procedure and how you would feel afterwards. N/A
How well did the staff protect your dignity and privacy?	How well did the staff protect your dignity and privacy? Excellent	How well did the staff protect your dignity and privacy? Fair	How well did the staff protect your dignity and privacy? Poor	How well did the staff protect your dignity and privacy? N/A
How well did the staff ensure your comfort?	How well did the staff ensure your comfort? Excellent	How well did the staff ensure your comfort? Fair	How well did the staff ensure your comfort? Poor	How well did the staff ensure your comfort? N/A
Please indicate your overall level of confidence in the care provided to you by the Surgery Center Staff.	Please indicate your overall level of confidence in the care provided to you by the Surgery Center Staff. Excellent	Please indicate your overall level of confidence in the care provided to you by the Surgery Center Staff. Fair	Please indicate your overall level of confidence in the care provided to you by the Surgery Center Staff. Poor	Please indicate your overall level of confidence in the care provided to you by the Surgery Center Staff. N/A
Please rate the cleanliness and appearance of the Surgery Center.	Please rate the cleanliness and appearance of the Surgery Center. Excellent	Please rate the cleanliness and appearance of the Surgery Center. Fair	Please rate the cleanliness and appearance of the Surgery Center. Poor	Please rate the cleanliness and appearance of the Surgery Center. N/A
How would you rate your overall Surgery Center experience to others?	How would you rate your overall Surgery Center experience to others? Excellent	How would you rate your overall Surgery Center experience to others? Fair	How would you rate your overall Surgery Center experience to others? Poor	How would you rate your overall Surgery Center experience to others? N/A

Other (please specify)

Question Title

* 4. Additional Information:

What did you like best about your experience of the Surgery Center?

What did you like least?

Do you have any additional comments or suggestions?

Question Title

* 5. Contact Information

Name

Email Address

Phone Number