Thank you for using West River Endoscopy. It is our goal to provide you and/or your family member with the best possible care. By completing this survey you help us improve our services. Your answers will be kept confidential.

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* 1. Who was your physician during your visit?

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* 2. Please rate the wait you had to get your appointment for your procedure at West River Endoscopy

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* 3. Please rate how long you spent waiting at West River Endoscopy before the procedure

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* 4. Please rate the personal manner (courtesy, respect, sensitivity, friendliness) of the physician who performed your procedure

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* 5. Please rate the personal manner (courtesy, respect, sensitivity, friendliness) of the secretarial staff who checked you in.

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* 6. Please rate the personal manner (courtesy, respect, sensitivity, friendliness) of the nurses and other support staff.

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* 7. Please rate the technical skills (thoroughness, carefulness, competence) of the nurses who prepared you for your procedure.

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* 8. Please rate the adequacy of the explanations of your procedure and what was done for you (all your questions answered).

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* 9. What was the level of pain during or after your procedure?

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* 10. What is your overall rating of your visit

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* 11. Would you have this procedure done again by the same physician?

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* 12. Would you have this procedure done again at this facility?

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* 13. Would you recommend this facility to your family members and/or friends?

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* 14. Was there anything we could have done better?

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* 15. Any comments?

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* 16. May we call you if we have additional questions?

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* 17. please enter (OPTIONAL)

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* 18. Date of Procedure

Date of Service

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* 19. If we may call you, best time to call

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