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Procedure Type: Surgical Colonoscopy/Endoscopy Pain Mgmt Other
Date of Procedure:
Name (Optional):
Doctor's Name (Optional):
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1. The information and instructions given to me by the Nurse during the PreOp phone call were:
2. At check-in, the ability of the staff to answer my questions was:
3. The level of personal interest and care I received from my Anesthesiologist was:
4. The courtesy and professionalism of the nursing staff toward me and my family member/caregiver was:
5. The Level of personal interest and care I received from my Doctor was:
6. The protection of confidentiality and my personal privacy was:
7. The cleanliness and comfort of the facility was:
8. The management of pain after my procedure was:
9. The instructions given to me upon discharge were:
10. My overall experience and the care I received at your facility was:
11. Did you experience any unexpected problems after your procedure? Yes No
If yes, please explain:
12. What did you like most about our facility?
13. What do you feel could have been improved upon at our facility?
14. Would you recommend our facility to your family and friends? Definitely Yes Probably Yes Probably Not Definitely Not
15. Please list any other comments or suggestions you might have:
16. Please list any employees that provided you with exceptional service: