Outpatient Surgery Patient Satisfaction Survey
Patient Information (Optional)
Name
Date of Surgery
About Your Visit
Type of Procedure
How would you rate the registration process?
Excellent
Good
Fair
Poor
Staff courtesy and professionalism:
Excellent
Good
Fair
Poor
Nursing care quality:
Excellent
Good
Fair
Poor
Physician communication:
Excellent
Good
Fair
Poor
Facility cleanliness:
Excellent
Good
Fair
Poor
Pain management:
Excellent
Good
Fair
Poor
Feedback
What did you like most about your experience?
What could we improve?
Additional Comments