* Indicates a required field.

Patient's Name:

* Date of Surgery:

1. Do you feel that your instructions prior to surgery were adequate?    Yes   No

2. Do you feel that the surgery center personnel were interested in you as a person?    Yes   No

3. Was the surgery center pleasant and comfortable?    Yes   No

4. Do you feel that the separation from your family member or friend was minimal?    Yes   No

5. If your child had surgery, did you feel that you were reunited as soon as possible?    Yes   No

6. Do you feel that you were given adequate postoperative instructions?    Yes   No

7. If you would have surgery again, would you consider returning to our facility?    Yes   No

8. How would you rate your overall experience at our facility?    Excellent   Good   Fair   Poor

9. Please list any general comments or suggestions you feel will help us to improve the quality of patient care at our facility.

Patient's E-mail Address:   (Optional if you want a confirmation e-mail message.)

(For security reasons, this must be an e-mail account, not a forwarding alias.)

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