Colonoscopy Patient Feedback Form
Patient Name
Date of Procedure
Email (optional)
How would you rate the bowel preparation instructions you received?
1
2
3
4
5
How comfortable were you during the procedure?
1
2
3
4
5
How would you rate the friendliness and professionalism of our staff?
1
2
3
4
5
Were your questions and concerns addressed adequately?
Yes
No
Somewhat
Additional Comments or Suggestions