* 1. Patient Name

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

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

* 4. Date the patient was admitted to the medical unit?

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

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

* 7. Were your discharge instructions clear and easy to understand?

* 8. Did you get a follow-up appointment made with your health care provider?

* 9. Did you get a prescription and were you able to get it filled?

* 10. Did you have any problems with pain or medication?

* 11. While admitted, were your food choices adequate?

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

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

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

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