* 1. Date of Visit:

* 2. Care Provider / Department

* 3. Which BCM facility did you visit?

* 4. For your appointment, was the scheduling process easy?

* 5. When you scheduled your appointment for today, was the scheduling agent courteous?

* 6. When you arrived at the front desk, were you greeted with "Welcome to Baylor College of Medicine, I can help you" or by your name?

* 7. Was the front desk staff courteous?

* 8. Did you receive adequate information in regards to delays?

* 9. Did the nurses/technicians introduce themselves by name?

* 10. Were the nurses/technicians friendly and courteous?

* 11. Did the nurses/technicians provide necessary information on the day of your procedure or test?

* 12. Did the nurses/technicians provide proper instructions about caring for yourself at home?

* 13. Do you have confidence in the skills of the nurses/technicians?

* 14. Do you have confidence in the skills of the physician?

* 15. Overall, were you satisfied with the care you received?

* 16. Would you recommend our facility to others?

* 17. Tell us more about how we can improve which will help us better care for you and other BCM patients.

* 18. Is there anyone you would like to recognize for providing outstanding service or care?

* 19. Would you like someone to contact you?

* 20. If yes, your name:

* 21. Preferred method to be contacted:

* 22. Phone number or email:

* 23. Best time to contact you by phone:

Thank you for your feedback.