Customer Satisfaction Survey Form

Patient Satisfaction Survey

Please take a moment to fill out our patient satisfaction survey for the Upper Peninsula Surgery Center.
Thank you for choosing Upper Peninsula Surgey Center for your procedure. To help assist in improving the care that we provide to our patients. Please answer all the questions by checking the box to the left of your answer.
Date of your procedure*

MonthDayYear
Date
1. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?*
2. Were you greeted with courtesy and respect with a smooth check in process?*
3. Was the facility clean?*
4. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand? Including possible side effects.*
5. Did your doctors and nurses explain your procedure in a way that was easy to understand?*
6. Discharge instructions include things like symptoms you should watch for after your procedures, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions?*
7. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?*
8. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?*
0 Worst Facility Possible and 10 Best Facility Possible
9. Would you recommend this facility to your friends and family?*
10. Please leave any additional comments you have below.
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Patient Satisfaction Survey