Patient Satisfaction Survey

Email Address: *

Enter your Physician in the space provided (optional/confidential):

Type of surgery: Local w/ Anesthesia Care

Procedure:

Date of surgery:

Did the registration personnel demonstrate courtesy and concern?
Rate the following questions from 1 - 5, with a 1 being Poor and 5 being Excellent.

1 2 3 4 5 N/A

If your procedure was delayed, were you kept informed?

1 2 3 4 5 N/A

Was the nursing staff professional and courteous?

1 2 3 4 5 N/A

Did you understand your discharge instructions?

1 2 3 4 5 N/A

If you had any complications after you returned home. please explain:

Pain Bleeding Excessive Nausea Infection Other

Please Explain:

What was your biggest concern before your procedure?

Pain Anesthesia Outcomes Other

Please Explain:

Please rate how Lattimore performed in regards to your concern mentioned above:

1 2 3 4 5 N/A

Would you return to this facility?

Yes No

Would you recommend this facility to others?

Yes No

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