* 1. The nurse/medical assistant made the pre-procedure and preliminary instructions clear to me.

* 2. The educational materials I received provided me with clear instructions for my procedure preparation.

* 3. The reception secretary verified my demographic information in a confidential manner.

* 4. The endoscopy center provided a clean environment.

* 5. The nursing staff provided competent care and made me feel safe/comfortable before and after my procedure.

* 6. The physician answered all of my questions to my satisfaction.

* 7. The nurse anesthetist answered all my questions to my satisfaction.

* 8. I felt comfortable during my procedure.

* 9. The total time I spent at the facility met my expectations.

* 10. I was provided with clear discharge instructions prior to leaving the facility.

* 11. I understood how to contact one of the physicians if I needed.

* 12. If you would like, please provide any additional comments or suggestions.

* 13. Your name (optional)

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