Patient Satisfaction Survey

1. My pre-surgery phone call and/or on-line instructions were clear, including when and if to refrain from eating.
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2. The registration process was prompt and efficient.
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3. The registration staff was courteous.
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4. I understood my personal financial responsibility.
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5. A clear explanation was provided by the anesthesia staff regarding my anesthesia care.
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6. The nurses and staff were helpful and sensitive to my individual needs and concerns.
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7. After my procedure, my experience in the recovery room was positive.
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8. A clear explanation of discharge instructions was provided to me and my escort.
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9. The facility was clean.
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10. I would recommend the Center for Advanced Surgery to a friend or relative.
YesNo

Patient Name

Date of Procedure

Surgeon Name

Date Completed