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 (Required.)

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

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

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

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

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

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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). (Required.)

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9. What was the level of pain during or after your procedure? (Required.)

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10. What is your overall rating of your visit (Required.)

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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

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

T