Outpatient Surgery Patient Feedback Form
Patient Information
Name
Date of Surgery
Procedure
Feedback on Your Experience
How would you rate your overall experience?
Excellent
Good
Fair
Poor
How well did the staff explain your procedure and answer your questions?
Excellent
Good
Fair
Poor
Was the facility clean and comfortable?
Yes
No
Were you satisfied with the outcome of your surgery?
Yes
No
Waiting time before your procedure
Short
Acceptable
Long
Additional Comments
Please share any comments or suggestions