Emergency Department Survey

We want to make sure we provide quality care in a safe environment with exceptional service to our patients. Your feedback regarding our services is very important to us. Please take a few minutes to complete this survey so that we can better serve you and our community. If you have concerns regarding the quality of your care, please contact Patient Experience at 307.688.1530.

Question Title

* 1. Date of visit:

Question Title

* 2. Please rate the following questions:

	Yes	No	NA
Were your discharge instructions clear?	Were your discharge instructions clear? Yes	Were your discharge instructions clear? No	Were your discharge instructions clear? NA
Were you able to make a follow-up appointment?	Were you able to make a follow-up appointment? Yes	Were you able to make a follow-up appointment? No	Were you able to make a follow-up appointment? NA
Were you able to fill your prescriptions?	Were you able to fill your prescriptions? Yes	Were you able to fill your prescriptions? No	Were you able to fill your prescriptions? NA

Emergency Department Survey

Question Title

* 1. Date of visit:

Question Title

* 2. Please rate the following questions:

Question Title

* 3. Is there anyone you would like to recognize?

Question Title

* 4. Additional Comments:

Question Title

* 5. Patient name (optional):