Satisfaction Questionnaire
We want to thank you for giving us the opportunity to care for you. It is important to us to know how our care impacted you and your family members. Your input is greatly appreciated, and we would like to request a few minutes of your time to fill out the following questionnaire. The goal of Vein Treatment Access Care is to provide you and your family members with excellent healthcare delivered by our highly skilled professional staff.
Please select the surgery or procedure type:
Dialysis
Vein
General Surgery
Please rate your experience in the following areas:
Poor
Fair
Good
Very Good
Excellent
1. Instructions given to you by the Vein Treatment Access Care prior to your surgery/procedure?
2. Admission/Registration process on the day of your surgery/procedure?
3. Discharge instructions given to you by the Vein Treatment Access Care for follow-up care after your surgery/procedure were clear?
4. Courtesy/Professionalism of your physician?
5. Courtesy/Professionalism of the nursing staff?
6. Courtesy/Professionalism of your anesthesiologist?
7. Courtesy/Professionalism of the registration staff?
8. Attention paid to your privacy during your surgery/procedure?
9. Family members are kept updated during your procedure?
10. Overall rating of care received during your surgical/procedure visit?
Additional comments for the surgery center staff:
Patient: Name: (optional)
Procedure Date:
-
Month
-
Day
Year
Submit
Should be Empty: