1. Default Section

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* 1. Who is your health insurance carrier?

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* 2. Ease of Scheduling your procedure

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* 3. Efficiency of check-in process

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* 4. Waiting time before the procedure

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* 5. The cleanliness and ambiance of the facility

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* 6. The professionalism of our receptionist

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* 7. The professionalism and empathy of our nursing staff

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* 8. The staff taking time to answer questions before and after the procedure

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* 9. Were the discharge instructions easy to understand?

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* 10. The feeling your physician listened to you

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* 11. The physician taking time to answer your questions before and after the procedure

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* 12. How friendly was your Anesthesiologist?

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* 13. Your level of comfort during the procedure

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* 14. Which physician performed your procedure?

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* 15. Your overall satisfaction with our facility

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* 16. Your overall satisfaction with the quality of medical care you received

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* 17. Is there any particular person(s) that made your stay better or worse and why?

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* 18. IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

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* 19. Can we use your comment(s) as a testimonial?  We will use your first name and last initial only.

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* 20. Date of your procedure

MM/DD/YYYY

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* 21. Name (optional):

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* 22. Your age

T