* 1. Patient Name

* 2. Who is completing this survey (patient, parent, spouse, etc.)

* 3. Date you were treated in our Emergency Department

* 4. How did you hear about Summit Pacific Medical Center (newspaper, friend/family, primary care provider, etc.)?

* 5. Would you like to be contacted by administration?  If so, please provide your contact information (phone, email, etc.)

* 6. Who was the doctor(s) that treated you today?

* 7. Who was your nurse(s) today?

* 8. Overall, how satisfied were you with the care your received?

* 9. Were you kept well informed about the procedures/time during your care?

* 10. Would you return to our Emergency Department for future medical needs?

* 11. Is there anyone you would like to recognize for having provided exceptional service during your visit?

* 12. Did you have any concerns regarding the level of care you received during your visit?

* 13. Do you have any suggestions on how we can improve our department?

Thank you for letting us provide your care!

T